Fast-Track Cities Best Practices Repository

Best Practice Information

Best Practice Title

PrEP app

Best Practice Type

• Intervention

Best Practice Domain

• Meeting the needs of key populations
• Other, Improving PrEP adherence

Best Practice Primary Audience

• Community
• Clinician
• Researcher/Academia

Best Practice Description

Introduction

Adherence is key in order for pre-exposure prophylaxis (PrEP) to be effective. As a method to increase adherence a diary-based mobile application for iOS and Android was introduced for participants of the Amsterdam PrEP (AMPrEP) cohort study.

Description

The app was developed for participants of the AMPrEP study. Participants could record their sexual behaviour and pill use in the app on a daily basis. Moreover, the app could be used as a reminder service to take PrEP and participants could receive visual feedback on their pill use and sexual behaviour. The app was introduced as part of the AMPrEP study in 2015. Adherence support through the app was offered in an extended version of the app during a randomised clinical trial. The extended app provided a visualisation of self-reported pill use and sexual activity.

Data Collection

Data of the app has been saved at a protected server of the Public Health Service of Amsterdam using a unique study number for each study participant. Acceptability of the app was measured via a questionnaire.

Results, Outputs, and Outcomes

App use over time has been analysed and published by Flinkenflugel et al. in 2019 (STD). Adherence to daily and event-driven PrEP is currently being analysed using the app data. Results regarding adherence to daily PrEP will be presented at Adherence 2020, Orlando, USA. Results regarding adherence to event-driven PrEP has been presented at NCHIV 2019, Amsterdam, the Netherlands and CROI 2020, Boston, USA.

Lessons Learned

The app was very well accepted by the participants, with the majority of participants finding the app useful and pleasant (see Table 1 and 2, send by email). There was no difference in acceptability of the app between users of the short and the long app (see Table 3, send by email). Adherence to PrEP was very good amongst users of the app. Unfortunately, not all participants completed the app on a daily basis, and some participants did not record anything in the app during the study period. For our analyses, this might have resulted in a selection bias of participants who did complete the app.

Conclusion

Providing an app during the AMPrEP study period might have helped participants to adhere better to PrEP, which is beneficial for the effectiveness of PrEP. After 12 months, 62% of AMPrEP participants were still using the app.

Supplemental Tools and Resources

• Table 1: Acceptability of Standard AMPrEP App Users 2016-2018
• Table 2: Acceptability of Extended AMPreP App Users 2016-2018
• Table 3: Comparison of Acceptability among Extended and Standard AMPrEP App users 2016-2018

Contact Information

Name: Vita Jongen & Mark van den Elshout
City: Amsterdam
Organization: Public Health Service of Amsterdam
Email: vjongen@ggd.amsterdam.nl, mvdelshout@ggd.amsterdam.nl

Best Practice Information

Best Practice Title

Golden Compass: HIV and Aging

Best Practice Type

• Intervention

Best Practice Domain

• Linkage to HIV care and support services
• Enhancing retention and long-term engagement in HIV care with viral load suppression
• Meeting the needs of key populations
• Improving health-related quality of life and quality of care

Best Practice Primary Audience

• Community
• Clinician
• Health Department or Ministry of Health
• Government/Policy Maker
• Donor

Best Practice Description

Introduction

We are working to address the increasing medical complexity and unique health related issues facing older adults living with HIV. Adults living with HIV are at increased risk for other conditions such as cardiovascular disease and osteoporosis and are often facing multimorbidity and polypharmacy. Geriatric conditions such as falls, cognitive concerns, and frailty occur at relatively younger ages than the general population, supporting the use of age 50 as “older” for people living with HIV. In addition to medical complexity, many older adults with HIV are dealing with mental health conditions and psychosocial challenges such as loneliness and isolation, substance use and stigma, including ageism. Our overarching objective is to develop a new HIV care model that supports long term care engagement and also expands the focus beyond viral suppression to improve quality of life and address comorbid and geriatric conditions for older adults living with HIV.

This is an emerging area and lessons learned from initial HIV and aging programs such as ours will have an important role in developing future interventions. Interventions for older HIV-positive adults will be increasingly needed as the population of people living with HIV continues to age.

Description

Program Overview: Ward 86 is a safety-net clinic for the city of San Francisco and provides comprehensive medical and psychosocial services to approximately 2400 low income and uninsured patients, of which 1200 are age 50 or older. The Golden Compass program was designed with input from patients and providers at Ward 86. Ward 86 is the program name came from focus groups of patients, where “golden years” was an acceptable term related to aging, and many patients noted difficulty navigating medical care. The concept behind the Golden Compass program is “helping people living with HIV navigate their golden years” with compass points focused on specific challenges: 1) Heart and Mind (Northern point) addressing cardiovascular disease and cognitive concerns 2) Bones and Strength (Eastern Point) focused on bone health, physical function 3) Dental, Hearing, and Vision (Western Point) to focus on appropriate screenings and linkage to dental, audiology and vision services, and 4) Networking and Navigation (Southern Point) focusing on addressing social isolation and community building.

List of current major activities:

• Weekly geriatrics consultation clinic; ½ day per week at Ward 86, led by geriatrician Dr. Meredith Greene
• Monthly cardiology consultation clinic; 1 day per month at Ward 86, led by cardiologist Dr. Priscilla Hsue
• Weekly support group, held in Ward 86 conference room; led by clinical social workers Myriam Beltran and Sandra Torres
• Weekly exercise class “Wellness Club”, held in ZSFG campus community center, led by community instructor Cynthia Simon
• RN visits for annual screenings for older adults; led by program RN Mary Shiels

Additional description of activities: Co-located or embedded specialty services (cardiology, geriatrics) within the Ward 86 clinic is intentional, based on patient input.   The weekly geriatrics clinic is led by Dr. Meredith Greene, a geriatrician and HIV specialist. Geriatric assessment and treatment plans are developed. Patients also meet with the clinic pharmacist, Dr. Janet Grochowski who conducts medication reconciliation and identifies medication concerns including drug-drug interactions. In 2020 we began with nurse led geriatric assessments, where clinic nurses meet patients at the time of routine primary care appointments to conduct standard geriatric screenings, to reach more patients. The weekly exercise class is developed to accommodate a wide range of physical activity levels and abilities; the instructor tailors exercises to individuals. The exercises are predominately chair based and persons in wheelchairs or who need other assistive devices participate. The weekly support group is co-facilitated by clinic social workers on Friday afternoons and includes a meal. On alternating weeks, guest speakers including those from other community organizations present to the group for patients to better understand local resources. Attendance for both the support group and Wellness Club is on a drop-in basis.

The program is multidisciplinary, and implementation involves clinicians in medicine, pharmacy, nursing and social work. We work with community partners such as the San Francisco AIDS Foundation, Positive Resource Center (PRC), and Alliance Health Project, and make referrals to their existing social and mental health services. We have streamlined referral processes and these agencies in turn refer clients to our program. We also receive input from the clinic’s community advisory board, which reflects the demographics of the overall clinic and half of the members are age 50 and older.

Data Collection

Data collected:
We are collecting programmatic data and impact data. Our outputs and outcomes are evaluated using an implementation science framework, RE-AIM (Reach-Effectiveness-Adoption-Implementation-Maintenance).

Examples of data collected and RE-AIM dimension:

• Demographics of patients who participate in ≥1 program component and clinical data such as CD4 T-cell count (cells/mm3) and viral load (Reach)
• Tracking geriatric and cardiology appointments including no-show visits and cancellations (Reach)
• Tracking class (e.g. Wellness club, support group, other class offerings) attendance (Reach)
• Acceptability of program by patients, providers (Effectiveness)
• Satisfaction with services- clinics and classes by patients and providers (Effectiveness)
• Patient reported outcomes including quality of life, satisfaction with medical care, prescribing outcomes (e.g. change ins polypharmacy, drug-drug interactions), identification of geriatric conditions (Effectiveness)
• Tracking provider referral patterns (Adoption)
• Feasibility of program components (Implementation and effectiveness)
• Fidelity to original proposed structure of clinics and programming (Implementation)

Data sources include electronic medical record, class attendance reports, surveys with patients and providers, and qualitative interviews with patients and providers. Qualitative interviews provide additional data on program effectiveness, as well as barriers and facilitators to RE-AIM dimensions.

We also track and describe activities involved in program implementation such as clinic processes and program advertising.

Results, Outputs, and Outcomes

We have conducted an initial evaluation of the program using data from the first year and a half of program implementation. The evaluation was conducted using the implementation science framework RE-AIM (Reach-Effectiveness-Adoption-Implementation-Maintenance). The full results are in a manuscript currently under review.   In the first 1.5 years, >200 patients participated in 1 or more program components with a reach of approximately 17%. With regards to effectiveness, satisfaction and acceptability of the program were high among both patients and providers. Greater than 90% of patients and providers reported being satisfied or very satisfied with the program overall and >90% found the program acceptable (assessed by asking if would recommend to someone else). The majority of providers (90%) felt the program improved the health of older adults at ward 86. Patients noted improvements in self-rated health with fewer reporting fair or poor health after being seen in geriatrics and cardiology clinics. An early evaluation of impact on prescribing measures showed a reduction in anticholinergic medications. In qualitative interviews, addressing mobility challenges as well as polypharmacy and pharmacist support was noted as valuable services by both patients and providers. Cognitive assessments were also valued by providers. Patients reported fostering new social connections as a benefit of participating in classes. Provider adoption was high, with 85% of providers referring at least one patient to geriatrics clinic and 60% referring at least one patient to cardiology clinic. Implementation of the program occurred largely as originally proposed.

Evaluation is ongoing and focused on additional effectiveness data as well as sustainability and maintenance of the program. We are currently reviewing data collected on patient reported outcomes such as quality of life and prescribing outcomes. We are also comparing patient reported outcomes in those who initially participated in the program to those who did not, to further evaluate program effectiveness.

Lessons Learned

A strength of our program is that we have been able to implement with high fidelity to our original proposal one of the first HIV and aging programs in the US and that we used an implementation science framework to guide the evaluation. Our initial results show that the program is acceptable to patients and providers and that they are satisfied with services. Preliminary data also shows improvement in patient reported outcomes, which we are now examining in more detail.   A challenge for us and for the field of HIV and aging is to define appropriate evaluation and outcome measures, since most HIV models are evaluated in terms of viral suppression outcomes. Determining the best quality of life measurements to use remains a question for the field. We did learn through our experiences, that mixed methods (quantitative and qualitative data) is important as patients and providers shared stories about their experiences and how they benefitted from the program (improvements in quality of life) which can be difficult to assess in surveys.

Another lesson learned is the ongoing challenge of framing or age-related services. Although we had high adoption by providers, reach was relatively lower. In interviews with providers, we learned that trying to refer to an “aging” program was still a barrier for many patients. Despite intentionally choosing a program name that avoids the word “aging” or “geriatrics” that it is still challenging to make a referral without discussing “aging.” Providers suggested framing services in terms of “staying healthy as you get older” or “living longer with HIV”, which we are currently incorporating into advertising for patients.

Options we are currently trying to expand the reach of the program and address sustainability include training nurses in conducting geriatric assessment and screenings, training staff and providers on geriatric principles and aging services and exploring other modalities for consultative services including e-consults and telemedicine. These are all options that are translatable to settings where there may not be an embedded geriatrician. We are currently partnering with the UCSF/Northern California Geriatrics Workforce Enhancement Program to train staff and providers at Ward 86 on the 4Ms framework of geriatrics (Mind, Medications, Mobility, Matters most).

Conclusion

Our preliminary outcomes data show benefit to program participants, who receive clinical services at an urban safety-net HIV clinic. The Golden Compass program is a best practice as we are addressing a relevant issue: the unmet needs of older adults, whose numbers will only continue to increase. We also found initial benefits to patients and to HIV care providers, all while drawing on existing clinic and local resources as much as possible. The Golden Compass program is developed and refined with ongoing input from community partners and older adults living with HIV.

To benefit older adults in other settings, we are also proactively working to outreach to other clinics. We specifically used an implementation science framework for our evaluation, as it helps to guide implementation to other settings. We know that any best practice program will need to be adapted to other settings based on local resources and proactively have identified areas that can be easily adapted to serve older adults in different regions. We have shared best practices both informally to other HIV clinics and more formally through presentations at conferences such as IDWeek (Implementation of an HIV and aging Clinical Program). We are also currently working directly with an HIV clinic in Minneapolis to adapt and evaluate the implementation of the program in their clinic.

The national Ryan White Care Act has used the Golden Compass program as an example and we are working closely with the HRSA HIV/AIDS Bureau to discuss how all or parts of the program can be adapted to Ryan White clinics across the US. We are also hopeful to share findings at the upcoming AIDS 2020 program to reach an international audience.

Supplemental Tools and Resources

• Manuscript: PLoS One 2018 - Patient and Provider Perceptions of Golden Compass HIV Program
• Poster: SGIM 2018 - Addressing Polypharmacy Among Older HIV Patients
• PowerPoint: Implementation of an HIV and Aging Program 2019

Contact Information

Name: Meredith Greene
City: San Francisco
Organization: Ward 86, Zuckerberg San Francisco General Hospital, UCSF
Email: meredith.greene@ucsf.edu
Phone number: 415-502-3626

Best Practice Information

Best Practice Title

Princess PrEP program and its contribution to the overall PrEP uptake in Bangkok and Thailand

Best Practice Type

• Intervention

Best Practice Domain

• Meeting the needs of key populations

Best Practice Primary Audience

• Community
• Clinician
• Health Department or Ministry of Health
• Implementing Partner
• Government/Policy Maker
• Donor

Best Practice Description

Introduction

According to UNAIDS data 2019, it is estimated that there are around 6,400 new HIV infections annually in Thailand. Over half of these new infections arises from key populations – including men who have sex with men (MSM), transgender women (TGW), people who inject drugs (PWID), and sex workers – and their partners. Approximately one third of key populations at high risk for HIV infection are living in Bangkok.

HIV pre-exposure prophylaxis (PrEP) using a fixed dose daily combination of tenofovir/emtricitabine (TDF/FTC), when taken as prescribed, reduces the risk of HIV acquisition by around 99%. However, very few health care facilities in Bangkok offer PrEP to key populations who engage in high-risk behaviors. Antiretroviral agents are regarded as highly specialized drugs, requiring infectious diseases specialists to prescribe them. However, many infectious disease doctors in Thailand feel reluctant to prescribe PrEP, due to concerns that PrEP might lead to risk compensation and increased condomless sex. Therefore, key populations experience major barriers in accessing HIV prevention services.

The Princess PrEP program started providing PrEP to key populations in 2016. The program was built upon the Key Population Led Health Services (KPLHS) model which operates under a client-centered approach. As part of the KPLHS model, service packages are designed and co-delivered by KP communities. Staff of community based clinics, who are members of key population themselves, are trained on gender sensitivity, basic HIV knowledge, HIV counselling, and ART and PrEP dispensing, thereby enabling them to provide HIV related services free from stigma and discrimination in settings easily accessible by key populations. The Princess PrEP program started providing PrEP to key populations in 2016. The program was built upon the Key Population Led Health Services (KPLHS) model which operates under a client-centered approach. As part of the KPLHS model, service packages are designed and co-delivered by KP communities. Staff of community based clinics, who are members of key population themselves, are trained on gender sensitivity, basic HIV knowledge, HIV counselling, and ART and PrEP dispensing, thereby enabling them to provide HIV related services free from stigma and discrimination in settings easily accessible by key populations.

Description

Since January 2016, the Thai Red Cross AIDS Research Centre (TRCARC), in collaboration with the USAID LINKAGES project, the Thai Ministry of Public Health, and the Thai Government Pharmaceutical Organization, has implemented the Princess PrEP program in nine community based clinics in 6 provinces in Thailand. Two of these clinics are in Bangkok: the Service workers in Group Foundation (SWING) and Rainbow Sky Association of Thailand (RSAT). Through the program, lay providers who are members of key populations themselves (KP lay providers) provide free PrEP to eligible clients, while facilitating good adherence to ensure PrEP effectiveness. Clients who receive HIV testing services at the CBOs will be assessed for PrEP eligibility such as HIV risk, and last date of risk exposure. Those who are eligible will be offered PrEP, and if accepted, community health workers dispense PrEP on the same day of presentation by standing order from doctors at partnering health care facilities. Blood will also be taken to evaluate hepatitis B serology and creatinine profiles; results will be reviewed remotely by an attending physician. Clients who initiated PrEP are required to repeat HIV testing at month 1 and every three months thereafter, while creatinine testing occurs bi-annually.

Data Collection

Routine programmatic data is collected. This dataset includes demographic characteristics, laboratory results, uptake cascade (HIV testing, at risk, eligible for PrEP, offered and accepted PrEP), adherence, effective use, and retention.

Results, Outputs, and Outcomes

In total, more than 6,000 clients have accessed PrEP through the program, contributing to almost half of Thai PrEP users, compared to less than 20% of the total being contributed through the national PrEP program implemented in public hospitals throughout Thailand. In Bangkok, as of February 2020, 3,766 key populations accessed free PrEP through Princess PrEP, 3,343 (88.7%) were MSM and 233 (6.2%) were TGW. Routine program data showed that of these clients, 65.1% completed follow up at Month 1, 51.9% at Month 3, 32.6% at Month 6, 23.5% at Month 9 and 16.9% at Month 12. Self-reported adherence was high among MSM with 99% of clients taking ≥ 4 pills/ week at Month 1, 98.6% at Month 3, 98.6% at Month 6, 99.2% at Month 9 and 99% at Month 12. Self-reported adherence among TGW was lower, with 85.7% of clients taking 7 pills/week at Month 1, 76.8% at Month 3, 88.6% at Month 6, 88.2% at Month 9 and 78.6% at Month 12.

Since 1 January 2019, evaluation of PrEP uptake is routinely conducted. Preliminary findings from this evaluation show that at the two community based clinics in Bangkok, 48.3% of HIV-negative clients who are offered PrEP because of self-reported risk behavior accept it. The main reason for not accepting PrEP is the perception of not being at risk for HIV, indicating a mismatch between risk behavior and self-perceived risk.

Lessons Learned

The Princess PrEP program has now contributed to almost half the number of total PrEP users in the country, of which almost four thousand key populations accessed PrEP through 2 community based clinics in Bangkok. Making PrEP available to key populations through KPLHS is feasible and effective in a KP-friendly, gender sensitive, and easily accessible setting. The community based clinics are located in hot spots and have flexible service hours to fit clients’ lifestyles and needs. These factors have led to the success of the program. The training and certification of KP lay providers to ensure high quality services are delivered to clients by their peers has been another major factor contributing to the success of the program.

Based on findings from the program, the National Health Security Office has decided to include PrEP in the Universal Health Coverage scheme, starting in 2020 with a pilot phase which includes 2,000 PrEP clients under the scheme, 850 of which will be enrolled through the KP-led PrEP program.

Although the cumulative number of KPs accessing PrEP through the program in Bangkok is impressive, and account for almost a third of all Thai PrEP users in the country, a recent PrEP target setting exercise by UNAIDS estimated that around 40,000 MSM and almost 4,000 TGW in Bangkok are at risk for HIV infection and would benefit from PrEP. Therefore, the scale up of KP-led PrEP is urgently needed.

Furthermore, PrEP uptake rates remain suboptimal, mostly due to a mismatch between actual risk and self-perceived risk. This needs be addressed in order to facilitate higher PrEP uptake rates among these key populations. Gain-framing messages around PrEP instead of loss-framing messages are shown to engage people in services regardless of self-perceived risk, and this approach to communication about PrEP could be the key to improving PrEP uptake.

Conclusion

Princess PrEP as part of Key Population-Led Health Services has demonstrated that PrEP can be demedicalized through KP lay providers in the community, and contributes to more PrEP users in less clinics compared to the national PrEP program in public health facilities. The program’s success has led to the inclusion of PrEP as part of Thailand’s Universal Health Coverage, and makes this a best practice in delivering PrEP to key populations. The success can be attributed to the client-centered approach, addressing stigma and discrimination which hinders the engagement of key populations in HIV services, and training and certifying KP lay providers to provide services to their peers.

Supplemental Tools and Resources

• Factsheet: Princess PrEP 2020
• Factsheet: KP-LED PrEP
• Poster: CROI 2019 - Factors Associated with Loss of Retention among PrEP Clients
• Report: Asia-Pacific Regional Consultation on PrEP Implementation 2019

Contact Information

Name: Nittaya Phanuphak
City: Bangkok
Organization: PREVENTION, Thai Red Cross AIDS Research Centre
Email: nittaya.p@prevention-trcarc.org
Phone number: +66818253544

Best Practice Information

Best Practice Title

Targeted testing and immediate initiation of treatment of acute HIV infection among men who have sex with men in Amsterdam

Best Practice Type

• Intervention

Best Practice Domain

• Finding and testing HIV unawares, especially young men and women
• Linkage to HIV care and support services
• Promoting early initiation of and adherence to HIV treatment
• Meeting the needs of key populations
• Facilitating an effective interface between health services/community services

Best Practice Primary Audience

• Community
• Clinician
• Health Department or Ministry of Health
• Implementing Partner
• Researcher/Academia
• Government/Policy Maker

Best Practice Description

Introduction

Men who have sex with men (MSM) with acute HIV infection (AHI) are a key source of new infections. To curb HIV transmission, we implemented at the Amsterdam sexually transmitted infection (STI) clinic a strategy for increased AHI awareness, rapid diagnosis of AHI, and immediate initiation of combination antiretroviral therapy (cART) in Amsterdam MSM. We assessed the feasibility and effectiveness of this AHI strategy in diagnosing AHI and decreasing the time to viral suppression in Amsterdam, and historically comparing this to changes in the time between diagnosis, cART initiation and viral suppression during prior calendar periods reflective of cART initiation guidelines.

Description

In August 2015, we implemented a strategy to increase AHI detection and immediately treat individuals with AHI (i.e. “AHI search and treat-to-suppression strategy” or in short, the “AHI strategy”). The AHI strategy included a combination of (1) an AHI awareness campaign and behavioural online intervention; (2) targeted point-of-care HIV-RNA testing with same-visit delivery of results; (3) same-visit referral to an HIV treatment centre; (4) intake at an HIV treatment centre within 24 hours of referral; and (5) immediate cART initiation at the HIV treatment centre.

The online intervention aims to increase awareness of AHI among Amsterdam MSM, help them self-identify AHI symptoms and increase their behavioural motivation to test. The online intervention has been designed in close collaboration with the MSM community, including HIV-negative MSM and MSM living with HIV. The online intervention includes a dedicated website (www.hebikhiv.nl/en) with information about AHI and immediate cART initiation, and a self-administered screening tool, based on a published AHI risk score. Next to this online referral, MSM can also be referred by their general practitioner or during routine STI screening at the STI clinic; eligibility is being assessed with the pragmatic AHI risk score.

The AHI strategy’s testing procedures include simultaneous rapid HIV antibody, fourth generation antigen/antibody, and qualitative point-of-care HIV-RNA testing (GeneXpert, Cepheid), and same-visit delivery of results. MSM identified with AHI are immediately being referred to an HIV treatment centre to initiate cART within 24 hours.

Key implementers and collaborators include the MSM community, STI/AIDS NL (a governmental organisation helping the public and professionals prevent, detect and treat HIV and other STIs), general practitioners in Amsterdam, the STI clinic of the Public Health Service of Amsterdam, HIV treatment centres (Academic and non-academic hospitals) in Amsterdam, and the HIV Monitoring Foundation. The project is part of the HIV Transmission Elimination AMsterdam (H-TEAM) initiative.

Data Collection

We included 63,278 HIV testing visits in 2008-2017, during which 1,013 MSM were HIV diagnosed with HIV at the Amsterdam STI clinic. We assessed the AHI strategy's effectiveness by comparing MSM tested via the AHI strategy to MSM tested via standard of care. Standard of care procedures included confirmation of HIV diagnosis within one week, referral to an HIV treatment centre within five days of confirmed diagnosis and cART initiation within one month. AHI diagnoses were assessed before and after implementation of the AHI strategy. Time from diagnosis to cART initiation and to viral suppression was compared for three cART initiation periods during which guidelines for cART initiation had changed: (1) 2008-2011: cART initiation if CD4<500 cells/mm3 (standard of care); (2) January 2012-July 2015: cART initiation if CD4<500 cells/mm3, or if AHI or early HIV infection (standard of care); (3a) August 2015-June 2017: universal cART initiation (standard of care); and (3b) August 2015-June 2017: the AHI strategy.

Results, Outputs, and Outcomes

Before implementation of the AHI strategy, the proportion of AHI of all HIV diagnoses was 0.6% (5/876); after implementation this was 11.0% (15/137). Median time from diagnosis to cART initiation was 439, 99, 29, and one day in period 1, 2, 3a, and 3b, respectively. Median time from diagnosis to viral suppression was 584 (IQR, 267-1065) days in period 1, 230 (IQR, 132-480) days in period 2, 95 (IQR, 63-136) days in period 3a, and 55 (IQR, 31-72) days in 3b, the AHI strategy.

Lessons Learned

The AHI awareness campaign did not only refer MSM to the STI clinic for testing, but also increased general awareness of AHI among MSM and health professionals. Specifically at our STI clinic, frontline workers started to see the importance of rapid detection of AHI, and immediate referral for cART initiation. Because of the observed feasibility, the intervention of the AHI strategy have now been implemented as standard of care for people with AHI at the Amsterdam STI clinic. We found the accelerated confirmation of diagnosis and linkage-to-care the components most valuable and easiest to implement, therefore, these interventions have now been implemented not only for people with AHI, but for all people newly diagnosed with HIV at the Amsterdam STI clinic. Unfortunately, due to limited resources and time constraints, MSM are assessed for eligibility for the AHI strategy at a health workers' discretion, i.e. if a health workers clinically suspects AHI. With increased budget and time available, ideally, all MSM visiting the STI clinic should be assessed for eligibility, and tested via the AHI strategy if eligible.

Conclusion

Implementing a strategy for rapid AHI diagnosis in MSM linked to immediate cART initiation at the Amsterdam STI clinic was feasible, associated with a higher AHI yield, and significantly decreasing the time from HIV diagnosis to viral suppression, when compared to standard of care. Immediate cART initiation has been shown to decrease time to viral suppression in different settings with limited to moderate access to healthcare, including for people with AHI. Our findings suggest that, even in the Dutch context, where health insurance is mandatory and covers cART, the interventions of the AHI strategy could have potential additional value in preventing onward transmission among MSM.

Supplemental Tools and Resources

• Targeted Screening and Treatment Initiation (IAS 2019 Abstract)

Contact Information

Name: Maartje Dijkstra
City: Amsterdam
Organization: Public Health Service Amsterdam
Email: mdijkstra@ggd.amsterdam.nl
Phone number: +31625087466

Best Practice Information

Best Practice Title

ENGAGE: Key population-led services which are certified, legalised and financially sustainable

Best Practice Type

• Intervention

Best Practice Domain

• Meeting the needs of key populations

Best Practice Primary Audience

• Community
• Clinician
• Health Department or Ministry of Health
• Implementing Partner
• Government/Policy Maker
• Donor

Best Practice Description

Introduction

Many interrelated factors affect the access to HIV services by key populations (KPs), causing the HIV uptake to remain low in this sub-populations. The KP-Led Health Services (KPLHS) model defines a set of HIV and health-related services that focus on specific key populations (KPs) including men who have sex with men (MSM), transgender women (TGW), male sex workers (MSW), transgender women sex workers (TGSW) and people who inject drugs (PWID). Under the KPLHS model, KP-community health workers (KP-CHWs) have their capacity built and strengthened to provide HIV services in partnership with the health sectors. These services are designed in consultation with KP members themselves and are, therefore, needs-based, demand-driven, and client-centered. This model is critical to fulfill the gaps along the HIV cascade by increasing the accessibility, availability, acceptability and improving the quality of health services for KPs.

Description

"The USAID Community Partnership Project, led by the Thai Red Cross AIDS Research Centre (TRCARC) and CBO partners, Rainbow Sky Association of Thailand (RSAT), Service Worker IN Group Foundation (SWING) and Mplus Foundation, has employed an integrated approach to formulate legalization for KP-lay providers to provide KPLHS during 2017-2020.

• In 2015, KPLHS model designed by MSM and TGW communities was established in 4 HIV-strategic provinces under USAID LINKAGES Thailand Project.
• In 2017, “ENGAGE”, the technical support and advocacy platform supported by USAID Community Partnership Project, established capacity building and certification system for KP lay providers to perform HIV/STI testing and dispense pre-/post-exposure prophylaxis (PrEP/PEP).
• In 2018, 55% of HIV testing and 55% of PrEP provisions among MSM and TGW in Thailand were conducted by KP lay providers. Large uptake of HIV testing and PrEP among KPs through KPLHS, in comparison to uptake at conventional services, have been vital in ENGAGE’s advocacy for the policy shift to legalize KP lay providers.
• In 2019, Prof. Emeritus Praphan Phanuphak, Director of the Thai Red Cross AIDS Research Centre, was recruited as a “policy influencer” to have both formal and informal dialogues with the Minister of Public Health, the Director General of the Department of Disease Control and other key high level of policy makers to address the concerns of the professional medical councils.
• A ministerial regulation sanctioning KP lay providers’ roles was signed by the Minister of Public Health on June 6, 2019 and promulgated in the Ministry’s gazette in September 2019. In addition, with collaboration among key stakeholders, a quality standards for HIV/STIs service delivery has been developed and launched out nationally. Moreover, national operation plan for KP-lay provider certification has been developed.

Data Collection

Since 2017, there are 6 training curricula developed and used to train 193 KP-lay providers, 77 completed all required courses and started practicum, and 25 received ENGAGE’s certification after completing practicum and competencies assessment and ready for national registration to be certified community health workers for legally providing KPLHS.

Results, Outputs, and Outcomes

Uptakes of HIV services have been enhanced in 9 priority provinces where trained and certified KP lay providers are delivering KPLHS to KP clients. There were 65,399 HIV testing, 2,259 newly diagnosed HIV cases and 3,227 individuals at high-risk for HIV acquisition who started PrEP during January-September 2019, compared to 24,003 HIV testing, 910 new HIV cases diagnosed and 978 individuals who started PrEP during the same period in 2018. These results demonstrated high feasibility and effectiveness of KPLHS to rapidly boost HIV responses in order to achive the ending AIDS’s goal by 2030.

Lessons Learned

National-level impact of the KPLHS, as well as formal capacity building and certification systems, were critical to achieving legal endorsement of KP lay providers. The “policy influencer” was instrumental in leading advocacy efforts to become successful within 1 year. Continuous engagement with key stakeholders and professional medical councils reduced the resistance to task shifting/task sharing policy change.

In addition, for CHWs certification, dedicated staff and time, along with clear guidance on the certification processes, were crucial to create and retain a cadre of certified KP lay providers. Moreover, turnover, internal staff movement, multiple duties and high work burden were key factors of KP lay providers not completing the certification process.

Conclusion

KPLHS has greatly contributed to the increased use and coverage of HIV testing and PrEP in Thailand as part of its National Strategic Plan to end AIDS. Certified KP lay providers are legally accepted as providers of quality HIV/STI prevention and treatment services. Certification of KP lay providers also helps to expand the career ladder for our community workforce. KPLHS has also been used for performance-based financing exercise in Thailand, as part of the initiative to direct domestic fund to community-based organizations who are providing KPLHS. With formal certification and financing mechanisms, KPLHS has now been institutionalized in Thailand’s public health system. Continuous efforts are still needed to strengthen KPLHS institutionalization for its sustainability.

Supplemental Tools and Resources

• Transitioning from International Funding to support KP-led Health Services (AIDS 2019 Poster)
• Institutionalize KP Lay Providers (AIDS 2020 Abstract)
• The Engage Approach (AIDS 2020 Abstract)
• HIV Rapid Diagnostic Testing (Journal of Virus Eradication 2018 Manuscript)
• Princess PrEP (Journal of Sexual Health 2018 Manuscript)

Contact Information

Name: Nittaya Phanuphak
City: Bangkok
Organization: PREVENTION, Thai Red Cross AIDS Research Centre
Email: nittaya.p@prevention-trcarc.org
Phone number: +66818253544

Best Practice Information

Best Practice Title

Same-day ART initiation in a non-hospital (non-ART) setting

Best Practice Type

• Intervention

Best Practice Domain

• Promoting early initiation of and adherence to HIV treatment

Best Practice Primary Audience

• Clinician
• Health Department or Ministry of Health
• Researcher/Academia
• Government/Policy Maker
• Donor

Best Practice Description

Introduction

In order to end the HIV epidemic, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has set the 90-90-90 targets in which, by 2020, 90% of people living with HIV (PLHIV) know their status, 90% of those have initiated antiretroviral therapy (ART), and 90% of those have reached viral suppression. In Bangkok, Thailand, Only 57% of people diagnosed with HIV are on treatment. The main barriers that interfere with the ability to achieve the second and the third 90 targets are loss to follow up after HIV diagnosis and delay in ART initiation. These may be due to convoluted processes in transferring PLHIV to their eligible hospitals, multiple visits for pre-ART counseling to promote long term adherence, long waiting time for baseline lab results, and difficulties in linkage to care. Additionally, stigma regarding HIV status and gender identity in the healthcare system may deter men who have sex with men (MSM) and transgender women (TGW), populations that are disproportionately affected by the HIV epidemic, from accessing ART.

In Bangkok, Thailand, linkage to ART service after HIV diagnosis were usually made through referral from HIV testing clinics to hospitals, which resulted in low ART initiation among PLHIV who have already known their positive status. To address this concern, a same day ART (SDART) initiation hub was established at the Thai Red Cross Anonymous Clinic (TRCAC) which is the largest HIV testing clinic in Bangkok. HIV positive clients, regardless of their health insurance scheme, can initiate ART on the same day of diagnosis without waiting for the baseline lab results if they are clinically eligible and ready. A team of peer navigators from diverse backgrounds is also integrated into the SDART service to navigate PLHIV through the barriers in Thailand’s healthcare system, link PLHIV to a long-term ART maintenance facility, and provide psychosocial support throughout the process. This intervention overcomes the structural barriers in the healthcare system, and has resulted in early linking to care for PLHIV who are willing to start ART, which has shown to facilitate viral load suppression.

Description

Since July 2017, the TRCAC began to offer SDART services, allowing eligible clients to start ART on the same day of HIV diagnosis, regardless of their health scheme coverage. This service provides ART for clients who are either newly diagnosed with HIV or re-engaged but ART naïve, who are willing to start ART and can come back to follow up visits, and do not have tuberculosis or cryptococcal meningitis, or other serious opportunistic infections that may interfere with ART initiation. The SDART initiation process at TRCAC takes about 2.5 months in total, and includes 2 visits (one after the clients test positive for HIV and one before the clients are referred to their long-term ART maintenance facility).

-The first visit takes place at TRCAC right after HIV diagnosis, during which clients receive post-test counseling, chest x-ray and blood draw for baseline tests according to the Thailand National Guidelines on HIV Treatment and Prevention (which recommends a list of baseline tests at the time of HIV diagnosis, such as creatinine, urinalysis, CD4 count, HBsAg, Anti-HCV, syphilis serology, and ALT). However, only chest x-ray results are needed for ART initiation. Clients will undergo psychosocial evaluation by a peer navigator and medical examination by a physician and nurse, after which ART is initiated for 2 or 3 weeks. The regimen prescribed is emtricitabine (FTC), tenofovir (TDF) and efavirenz (EFV). During the 2- or 3-weeks period, the peer navigator will contact clients by LINE application or phone call to follow-up on side effects that might occur, support adherence, and also remind and confirm with clients for the follow-up visit.

-The second visit takes place at 2- or 3- weeks after ART initiation. Clients will come back for baseline test results, evaluation of ART side effects, ART modification if needed, and assistance with transferring their health insurance scheme to a more convenient facility if needed. Clients will receive a 2-month prescription of ART to be taken during the transition period to the long-term ART maintenance facility.

The service is run by a team of counselors, peer navigators, nurses and physicians. The counselors perform pre- and post-test counselling, and psychosocial evaluation, and guide the clients through their decision to enter the SDART process. The peer navigators evaluate client’s willingness to start ART, conduct psychosocial assessment, preliminary opportunistic infection screening, provide pre-ART counseling to promote long term adherence, and facilitate the health insurance scheme transfer and refer out processes. The nurses take medical history before ART initiation to screen for tuberculosis or cryptococcal meningitis. The physicians conduct physical examination, evaluate the client’s overall readiness to start ART, and prescribe ART.

Data Collection

Routine programmatic data is collected. This dataset includes demographic characteristics, clinical characteristics, laboratory results, screening cascade (eligibility, acceptability, initiation), time to ART initiation, retention, and viral load suppression.

Results, Outputs, and Outcomes

The results from the TRCAC show high level of acceptability overall (90.4%), with 94.4% acceptability among newly diagnosed clients and 85.3% among re-engaged clients. When stratified by populations, the acceptability rate is 84.9% among the general population, 92.2% among MSM, and 94.1% among TGW. Among those who can start ART, 79.4% can start ART on the same day, 8.2% can start within 1-2 days, and 9.1% can start within 3-7 days. When compared to historical data at TRCAC, SDART clients are 3.9 times more likely to start ART when compared to standard of care arm (HR: 3.9; 95% CI: 3.7-4.2; p<0.001). For clients who require health scheme transfer, the successful transfer rate is 89.64%.

Follow up data shows that 92.2% of clients are still retained in care at month 3 and 91.0% of clients are still in care at month 6. Additionally, 93.9% of clients who received viral load testing were virally suppressed with the median time to viral load suppression (interquartile range) of 162.5 (130-188) days. When compared to historical data at TRCAC, SDART clients were 2.2 times more likely to be virally suppressed when compared to standard of care arm (HR: 2.2; 95% CI: 1.9-2.6; p<0.001).

Lessons Learned

The SDART initiation hub model at the TRCAC shows that it is feasible and safe to start ART as early as possible after the clients are notified of their HIV positive result. Moreover, laboratory results are not required for SDART initiation, which can significantly reduce time to ART initiation. Furthermore, a team of peer navigators can provide psychosocial support and assist clients with navigating through the process of health insurance scheme transfer and with the referral to long-term ART maintenance facilities. Nonetheless, the SDART initiation hub model is a labor-intensive intervention, particularly for peer navigators, and despite data supporting SDART initiation, some conventional healthcare professionals still have concerns regarding clients’ readiness and safety. There are still physicians and healthcare workers who require CD4 and/or baseline lab results to start ART, and this can delay linking people living with HIV (PLHIV) to care, or result in losing clients before ART initiation. This will be a challenge for the scale up of SDART.

Conclusion

Evaluation of the SDART initiation hub at the TRCAC has shown the model works for all populations, including key populations such as MSM and TGW. Clients in the SDART program were 3.9 times more likely to start ART and 2.2 times more likely to achieve a suppressed viral load than people who started ART in the standard of care arm. In Thailand, based on findings from the TRCAC, SDART has been scaled up in nine healthcare facilities in five HIV high-burden Thai provinces using three different models, which are all in line with the Thailand National Guidelines on HIV Treatment and Prevention. The first model does not require laboratory results prior to ART initiation, the second model requires CD4 count prior to ART initiation, and the third model requires safety laboratory results but not CD4 count prior to ART initiation. The first model (not using baseline laboratory results) results in faster ART initiation, with no increase in severe adverse events or deaths compared to the other two models. SDART should be considered a best practice for expediting linkage to ART for PLHIV who know their status, which will also facilitate them to achieve viral suppression. It is a simple model that is easy to replicate, although with some initial investment in re-organizing clinic flow and providers’ mindset, and has an extensive impact on PLHIV and the potential to change the course of the epidemic.

Supplemental Tools and Resources

• Same-day ART Initiation (Factsheet)
• Same-day ART Initiation in Thailand (CROI 2019 Poster)
• Characteristics of clients with STI-HIV co-infection and SDART (IAS 2019 Poster)
• Engagement of Peer Navigators for SDART (IAS 2019 Poster)
• TDF-based Regimens (IAS 2019 Poster)
• Transgender-Led Same-Day ART (IAS 2019 Poster)

Contact Information

Name: Nittaya Phanuphak
City: Bangkok
Organization: PREVENTION, Thai Red Cross AIDS Research Centre
Email: nittaya.p@prevention-trcarc.org
Phone number: +66818253544

Best Practice Information

Best Practice Title

Integrated Hormonal and Sexual Health Services for Transgender Women (Tangerine Community Health Service)

Best Practice Type

• Intervention

Best Practice Domain

• Improving health-related quality of life and quality of care

Best Practice Primary Audience

• Affected Communities
• Clinical/Service Provider
• Health Department
• Implementing Partner
• Government/Policy Maker
• Donor/Payor

Best Practice Description

Introduction

Transgender individuals, specifically transgender women (TGW) and transgender women sex workers, are at elevated risk of HIV infection in the Asia-Pacific region and globally – the 2016 UNAIDS Prevention Gap Report estimates that worldwide, TGW are 49 times more likely to have HIV than the general populations. Despite this, TGW face multiple barriers to accessing necessary prevention, care, and treatment services, as well as legal and regulatory barriers, widespread stigma and discrimination. In many settings, there is a lack of transgender-sensitive health care providers trained to offer medically appropriate services. In addition, national HIV programs mainly target men who have sex with men (MSM) and normally combine TGW under MSM umbrella, overlooking their different gender identity and unique health needs.

Established in 1991, the Thai Red Cross AIDS Research Centre (TRCARC)’s Anonymous Clinic, the first HIV voluntary counseling and testing (VCT) clinic in Asia, found it challenging to reach to TGW in Bangkok. There were very few TGW clients receiving HIV testing each year. Little data on HIV and other risk behaviors were also known from these vulnerable populations.

Through the national transgender community consultation on research for piloting transgender health service model in 2015, it was decided that TRCARC established a transgender health clinic, which gender affirming hormone treatment (GAHT) must integrate into HIV and sexual health services for transgender people. The transgender community also agreed upon to name “Tangerine Clinic” with the primary objectives of providing transgender-competent healthcare services and conducting transgender-focused research in Bangkok, Thailand.

Description

Situated at the TRCARC in Bangkok, Tangerine Clinic aims to meet the unmet transgender health needs by offering comprehensive, fee-based health service packages covering GAHT, HIV counseling and testing, management of sexually transmitted infections, vaccinations for viral hepatitis A, hepatitis B and human papillomavirus (HPV), antiretroviral treatment (ART), and HIV pre- and post-exposure prophylaxis (PrEP and PEP).

In addition to gender-sensitive nurses and physicians, Tangerine also employs transgender staff, including transgender staff who are living with HIV. Tangerine remains in close contact with the community it serves, a method that has proven essential to ensuring that the clinic continues to offer accessible, transgender-sensitive and quality services.

Data Collection

Data have been collected under the prospective cohort study titled “The behavioral and psychosocial characteristics of clients accessing services at the Thai Red Cross AIDS Research Centre”.

In addition, Tangerine Clinic also reports routine programmatic data as custom indicators to the US President’s Emergency Plan for AIDS Relief (PEPFAR) under the United States Agency for International Development (USAID)’s LINKAGES Thailand Project, which is managed by FHI 360.

Results, Outputs, and Outcomes

In the past four years, there were 3,348 transgender clients with more than 12,000 visits receiving health services at the clinic. Of those, 3,130 were TGW and 218 were transgender men (TGM). HIV testing uptake was 94% among TGW and 95% among TGM, which 10% of TGW tested HIV-positive and 97% successfully initiated ART, mostly on the same day of diagnosis. There were no TGM tested HIV-positive.

Syphilis testing uptake among TGW was 71% (n=2,221) and 11% tested reactive.

However, it is quite challenging in increasing PrEP uptake among TGW who are at substantial risk of HIV acquisition. Only 11% of HIV-negative TGW were prescribed PrEP, while 12% of HIV-negative TGW were prescribed PEP after having exposed to HIV risk behaviors within 72 hours.

The data compared between TGW who received GAHT services and those who did not. TGW who received GAHT services were more likely to have subsequent visits (44% vs 34%, p<0.001), repeat HIV (32% vs 24%, p=0.002) and syphilis testing (26% vs 16% (p=0.001), and were more likely to take PrEP (12% vs 7%, p=0.006).

Tangerine Clinic also served TG people who were socio-economically marginalized and vulnerable to HIV acquisition. At baseline, 57% of TGW had below bachelor’s degree education, 27% unemployed, almost 20% engaging in sex work and almost 10% using amphetamine type stimulants (ATS).

Recently, Tangerine has also worked with popular transgender social media influencers to reach online TGW at substantial risk for HIV infection, including transgender youth and first-time HIV testers.

Lessons Learned

Meaningful engagement of transgender community at design, implementation and throughout the process is key in achieving the epidemic control. TRCARC recognized the active participation of the Thai transgender community contributed to the establishment of the Tangerine Clinic. In this case, transgender community was able to raise their voices and involved in any decision making that affected to their rights to health.

In addition, equal partnership between healthcare providers and transgender community has facilitated smooth service provision. Healthcare providers has gained trust from the transgender community. Therefore, the Tangerine Clinic has been currently well received among the Thai transgender community and other transgender networks in Asia region.

Moreover, Tangerine Clinic has strengthened the clinical capacity of transgender people to become frontline clinic staff. This effort has led to building self-esteem and community empowerment among transgender staff at the clinic.

Research studies around transgender health were primarily conducted based on the needs of and in consultation with transgender community.

Finally, TRCARC leadership has played pivotal roles since at the nascent stage and has maintained continued support for the clinic implementation. Without the supportive environment from senior staff, the Tangerine Clinic would not be able to serve transgender clients.

Conclusion

The integration of hormone services has not only coincided with increases in service uptake; additionally, preliminary data suggest clients who receive such services are more likely to return to the clinic for follow-up visits. The Tangerine model that integrates gender affirmative hormone treatment services and sexual health services is feasible and effective in increasing access to and retention in HIV testing and PrEP services.

There has been significant interest from medical institutions and community health centers in the country and from countries within the Asia-Pacific region to learn from and replicate the Tangerine model in diverse settings over the past few years of the Tangerine’s implementation. In response to this need for propagating best practices regionally and internationally, TRCARC has established the Tangerine Academy for Transgender Health as a South-South technical assistance platform for the development and sharing of tools, training curricula, and learning resources to support further roll-out of HIV and health service models for transgender people. The Tangerine Academy has provided technical assistance and capacity strengthening interventions on transgender health and HIV to community-based health clinics and key population friendly clinics in the Philippines and Vietnam in 2019. In 2020, the Tangerine Academy team has planned to provide technical assistance to USAID-funded community health clinics in Myanmar and Nepal.

Supplemental Tools and Resources

• Tangerine Health Center (Factsheet)
• Transgender-Led Social Media Interventions (IAS 2019 Poster)
• Integrated Gender Affirmative Hormone Treatment among TGW (AIDS 2018 Presentation)
• Transgender Competent Care (2019 Report)

Contact Information

Name: Nittaya Phanuphak
City: Bangkok
Organization: PREVENTION, Thai Red Cross AIDS Research Centre
Email: nittaya.p@prevention-trcarc.org
Phone number: +66818253544

Best Practice Information

Best Practice Title

Zero HIV Social Impact Bond (SIB) 

Best Practice Type

• Intervention

Best Practice Domain

• Finding and testing HIV unawares, especially young men and women 
• Linkage to HIV care and support services 
• Promoting early initiation of and adherence to HIV treatment 
• Addressing disparities in access to/utilization of HIV services 
• Facilitating an effective interface between health services/community services 
• Eliminating stigma/discrimination, notably within health settings 
• Accelerating uptake of proven interventions/policies/diagnostics/medicines 

Best Practice Primary Audience

• Clinician
• Health Department or Ministry of Health
• Government/Policy Maker
• Donor

Best Practice Description

Introduction

Within England, there are an estimated 6,700 people unaware of their HIV-positive status (PHE 2019). While HIV prevalence across England is relatively low, rates differ significantly across regions. The south London boroughs of Lambeth, Southwark, and Lewisham (LSL) have amongst the highest rates of prevalence. For each 1,000 people aged 15-59 in Lambeth, there are 15.7 cases of HIV, for Southwark 12.2 and Lewisham 8.4. There are estimated to be 1,000 PLHIV within LSL who are unaware of their HIV-positive status (LSL Sexual and Reproductive Strategy 2019). A further problem is the high number of people in LSL who are diagnosed late with HIV, (25%) which is associated with increases in morbidity and mortality, HIV transmission to others, and costs to the health service. Certain groups had a higher proportion of late diagnosis, including those aged 50-64 (53%), those identifying as Black African (49%), those whose route of transmission was through heterosexual contact (59%) and women (59%).  

Within these three boroughs there were 8,700 PLHIV who accessed care in 2016. A disproportionate amount of this group comprises minority populations, including Black Africans, migrants, and MSM. Across LSL the majority (76%) of HIV diagnoses are in men. Of all men living with HIV in LSL, nearly two thirds are white, and of women, nearly two thirds are Black African. The high prevalence of diagnosed HIV in LSL is driven by high population turnover including high rates of external migration, a high population of LGBTQI+ people, and a very diverse populations in terms of ethnicity, In addition to individuals who are unaware of their HIV-positive status, there is a substantial population of PLHIV who disconnect from treatment at some point after receiving a diagnosis. In a longitudinal study conducted by Jose and Delpech (2018), researchers found that 19% of patients living with HIV in the UK become lost to clinical care over the 10 years since they first entered treatment.  

Regardless of if the patient has knowledge of their HIV-positive status, lack of HIV treatment implies serious consequence for their health and wellbeing, as well as presents a significant barrier to reducing the number of HIV transmissions to zero by 2030. This intervention was designed to target all people living with HIV in LSL who are not currently on treatment and actively bridge barriers that prevent them from accessing HIV care.  

Description

The Elton John AIDS Foundation (EJAF), along with private and public sector partners, is addressing the previously described problem by implementing the world’s first Social Impact Bond (SIB) focused on HIV treatment and care. This work incorporates numerous stakeholders in different roles, including outcomes funding, capital investment, outcomes validation, and service delivery. The private organizations funding and leading this work are EJAF, The National Lottery Community Fund, ViiV Healthcare, Big Issue Invest, and Comic Relief. The public organizations involved in a leadership and advisory capacity are Lambeth Council (note that Lambeth Council also has contributed to funding), Lewisham Council, and Southwark Council. Finally, service providers in this work include Kings College Hospital, Lewisham and Greenwich Trust, Guys and St Thomas’s Hospital Trust, One Health Lewisham, Lambeth Health Limited, Metro Charity, and Naz Charity.  

There are a wide variety of settings for interventions, and interventions themselves are strategically tailored. Clinicians in EDs and primary care are offering universal or substantially increased HIV testing, as well as following up with patients who are disengaged from care through phone calls, video, or post. In other cases, providers from charity organizations are meeting individuals with HIV in community spaces where they already spend time and socialize. They are building trust-based relationships and starting conversations about health in non-judgmental ways. All these activities have the end goal of linking people living with the disease to HIV treatment and care. 

Data Collection

Our providers report total HIV tests at an aggregate level, as well as detailed anonymized data describing the demographics of all individuals linked to HIV care through the SIB. Data fields are modelled on those used by Public Health England. These include gender, ethnicity, exposure category (undetermined, heterosexual contact, sex between men, mother to child transmission, injecting drug use, blood products), test result (reactive, indeterminate, insufficient), CD4 count, lower super output area (geographical hierarchy in England), case outcome (known positive/new positive/negative/re-engaged/non contactable/disengaged/awaiting outcome). A detailed data sharing agreement has been developed to prevent the sharing of any PII, and all service providers have read and consented to adhere to this agreement. This includes provision ensuring that, as data is uploaded by each provider, individual patient data undergoes an irreversible process of anonymization.  

This data can be aggregated to provide profiles to examine impact across different variables. For example, data can be viewed filtered by provider type (e.g., hospital ED testing), by geographical location (e.g., individual borough), or by clinical indicators (e.g., CD4 count). Costing data is collected on provider recruitment, though as this is an outcomes-based payment mechanism, it is not regularly monitored after initial recruitment. Payments are based on outcomes achievement rather than provider costs, so it is up to providers to manage their costs accordingly. We are additionally planning a health economics review as part of a wider implementation science review.  

Results, Outputs, and Outcomes

Two project outcomes dictate activities and determine payment:  

(1) New patient diagnosed with HIV and engaged into HIV care 

(2) Previously diagnosed patient re-engaged into HIV care.  

These quite narrowly defined outcomes are a strength of this Social Impact Bond model, as stakeholders across the project are focused on these two metrics. The SIB also allows a great degree of flexibility in reaching those two outcomes, so that service providers can rapidly innovate and improve their services as they see what works to reach the most people. Since the SIB began providing services in Nov 2018, 122 people have been newly diagnosed and engaged in HIV care, and 89 people have been re-engaged in HIV care. Furthermore, more than 125,000 people have received HIV testing. The timing of diagnosis for SIB outcomes are particularly interesting. The LSL Sexual and Reproductive Rights strategy (2019) reported 25% of new diagnoses were late (CD4 count < 350) diagnoses. Within the SIB, late diagnosis is significantly more common, with 65.4% of new diagnoses qualifying as late. These higher-than-normal rates of late diagnosis exist across all service providers but are especially profound in new diagnoses found through Hospital ED testing (rates of 69.2% and 80.5% at the two-participating hospital EDs), suggesting that this is a highly effective intervention to identify PLHIV with a late diagnosis. We are working with Kings College London to carry out a research study of the effectiveness of these interventions and anticipate publishing within a peer reviewed journal such as Implementation Science in early 2022.  

Lessons Learned

One of the SIB’s most significant strengths has been that the model places focus on the patients themselves and utilizes bespoke approaches to engage those individuals in HIV services. This implies that hospitals, GP surgeries, and community groups each considered which activities to adopt to target people who do not know their HIV status or people who have left care. Several factors underpinned the success of the interventions, including sharing of practice across organizations (e.g., protocols for re-engagement were shared between hospitals) and enhanced collaboration between primary care and hospital HIV staff (e.g., a GP sitting in with clinic staff to encourage mutual learning and insights). Perhaps most significantly, individual teams were asked to consider what was best for their patients and were given resources to set up new systems to tailor their services based on their understanding of their patients’ needs. The initiatives therefore provide a range of pathways for hard-to-reach patients.  

Further, the modality of outcomes-based commissioning is, in itself, innovative, and represents a deliberate effort to prioritize end results, rather than daily activities. The approach means providers are goal-orientated and can take ownership of their own work. It also means that they have to consider what will work to bring patients into care – which frequently fosters creativity and continuous improvement. The model represents a shift away from a business as usual approach, which may struggle to reach or engage harder-to-find patients. It places greater focus on patients themselves and utilizes a bespoke approach to engage individuals in HIV services. This project has proved that diverse stakeholders can come together to develop varied but connected HIV activities across a complex health system. A key feature of the project is the way it allowed for private investors to inject capital into the public provision of HIV services – but only for the short term. By proving the benefits of preventative services and by bringing public stakeholders along through the process, it took on financial risk and intensive project management effort that might have been prohibitive (based on many competing priorities) for the NHS to set up.  

After we have proved the effectiveness of specific activities in surfacing outcomes, we are connecting those to NHS savings, and making a strong argument for the NHS and local authorities’ continued provision of the services. We cannot make a long-term impact unless we prove with this short-term project that there is opportunity to invest and achieve our outcomes. This process is already underway, based on our existing engagement with NHS stakeholders and LSL council commissioners. Future SIBs should similarly take a long view to consider what services they will implement in the short-term through their SIB, and how public organizations would integrate those services into public provision if the SIB is successful. 

Conclusion

More than 200 people so far are now receiving HIV treatment and care as a result of our SIB successfully focusing attention on the engagement of people living with HIV into treatment. Without this SIB, those individuals would likely still be disconnected from treatment, implying direct individual health risks and broader community risks of transmission. The people linked to care include many from key populations, but also people who consider themselves “low risk” or “no risk,” and who would not have proactively sought HIV testing. We believe these interventions to be best practice, not only because HIV testing in ED and primary care in areas of high prevalence is included within the NICE 2016 HIV testing guidance, but because by focusing on three boroughs of high incidence of HIV, we have gathered evidence of the interventions which show where health systems can make the biggest comparative gain in identifying people who are unaware of their HIV status, and how to effectively reengage those who are lost to follow up. We will be including this evidence of best practice in our submission within the HIV Commission Report and will play an active part in influencing the take up of this practice in other settings within the UK. We are also seeking to disseminate our evidence across clinician and commissioner networks both within the UK and beyond. We will be glad to discuss further to determine what materials may be most useful for those accessing Fast Track Cities Best Practices. 

Sustainability/Continuity during COVID-19

As UK COVID-19 rates rapidly increased in March 2020, the new pandemic introduced challenges to all providers. Hospitals experienced significantly reduced footfall in ED, GP practices abruptly ceased face-to-face appointments, and community groups had to pause all venue-based and in-person testing. In this way, service providers’ strategies for achieving outcomes were suddenly threatened. The Government Outcomes Lab (GO Lab) within Oxford University’s Blavatnik School of Government provides a useful framework to consider the alternative approaches for Social Impact Bonds amidst the COVID-19 pandemic (https://golab.bsg.ox.ac.uk/community/covid-19-resource-hub/selecting-alternative-funding-arrangements-uk-sibs-response-covid-19/). These approaches range from “no contract alteration” to “temporary switch to fee-for-service” to “terminate the contract”, with increasing departure from original outcomes-based contracts. Within our SIB, we decided that “no contact alteration” was the best path forward in both protecting the integrity of our model, and potentially paradoxically, in supporting our providers. As the contracts were outcome-based without specific requirements on activities that the providers needed to complete, providers were able to shift activities as needed to fit new parameters that COVID-19 had introduced.  

Total outcomes decreased rapidly during the first few months of the COVID-19 pandemic from 17 in February to 11 in March and 7 in April. Our top priority was continuing any level of service possible given the new conditions. This was very much grounded in listening to the providers and understanding the parameters they were working with, including distancing restrictions, increased workload, and changed processes.  

The adjustment process was unique to each provider and looked distinctly different based on provider type. Amidst total bloods being drawn in ED falling, hospitals were able to increase percentages of those bloods that were tested for HIV by communicating with clinicians about high-profile stories about people found through HIV testing and the potential to use HIV as part of differential diagnosis. GP practices similarly used the pandemic to communicate with their own clinicians about patients who might be immunocompromised due to untreated HIV. Both hospitals and GP practices strengthen their attempts to re-engage patients who were known to be HIV-positive but who had disconnected from treatment. Community groups went a different direction altogether, developing capabilities to reach people with remote methods, including online engagement and remote self-testing.  

Overall, we were extremely impressed by our providers’ ability to adjust and continue their SIB work. The effects of these adjustments combined with decreased rates of COVID-19 were visible by early summer, with outcomes at 12 in June and 15 in July. The adjustments that providers have made during this time have three interconnected benefits. First, and most obviously, they resulted in higher numbers of PLHIV connected to care. Second, they have strengthened the providers’ and the project’s resilience to future disruptions, as providers have built capabilities and made contingency plans that will support them in a potential second wave. Finally, the introduction of new activities (e.g., remote testing conducted by community groups) will allow us to build a more robust evidence base which includes the impact of such activities. 

Contact Information

Name: Steve Hindle 
City: London  
Organization: Elton John AIDS Foundation 
Email: steve.hindle@eltonjohnaidsfoundation.org  
Phone number: +44 (0) 20 7603 9996 

Best Practice Information

Best Practice Title

Keep Doing It London

Best Practice Type

• Intervention

Best Practice Domain

• Finding and testing HIV unawares, especially young men and women
• Promoting early initiation of and adherence to HIV treatment 
• Meeting the needs of key populations 
• Facilitating an effective interface between health services/community services 
• Eliminating stigma/discrimination, notably within health settings 
• Accelerating uptake of proven interventions/policies/diagnostics/medicines  

Best Practice Primary Audience

• Community

Best Practice Description

Introduction

The program was established in 2014 in order to tackle (then) rising HIV incidence in Greater London. It is a community-based program consisting of two broad workstreams: a public health awareness HIV campaign promoting combination prevention to all affected populations; and services for London's MSM (condoms, health promotion, HIV testing in community settings and commercial venues). 

Description

Do It London public health campaigns are multi-media integrated social marketing across a range of platforms, targeting key communities (MSM, Black Africans, sex workers) as well as ALL Londoners. This is managed and delivered 'in house' by the LHPP office on behalf of London's 32 borough authorities. LHPP MSM Outreach/Testing/Condoms is commissioned/outsourced to the voluntary sector, which delivers the service in commercial venues such as gay bars, clubs, and saunas. 

Data Collection

Variety of comprehensive monitoring data were collected for each workstream. For the campaign, we use a combination of quantitative marketing metrics and analytics to establish reach, awareness, follow through and action. This is complemented by qual research and evaluation of each annual campaign, as well as pre-testing audience engagement to help design the content and route to community reach.  

For the outreach/condom/testing campaign, we collect a range of quarterly output monitoring data (e.g., number of men engaged, type of intervention, HIV test offered, taken, result etc.) alongside some more detailed qual/quant data about MSM attitudes and behaviors related to HIV and sexual health (known as the 12Q survey). 

Results, Outputs, and Outcomes

Monitoring data reveals a wealth of effective outputs, on both workstreams. The program was independently evaluated after two years by University College London and found that it was, even in its initial phase, leading to a statistically significant increase in uptake of HIV testing among both MSM and Black Africans. Each year the Do It London campaign is independently evaluated - both qualitative research into user attitudes, views and self-reported behavior change as a result of engaging with the campaign, alongside a detailed Post Campaign Analysis. This is too detailed to describe here but, for example, it has consistently shown high levels of reach, engagement, and activity as a result of the campaign, exceeding KPIs on all media, especially Twitter and Facebook engagement.  

The campaign was awarded National Campaign of the Year 2018 at a prestigious competition assessing non-profit marketing campaigns, with the judges assessing the work as using data and evaluation particularly well to reach key audiences. It has been widely recognized that the London HIV Prevention Programme, including the DO IT LONDON campaign, has contributed to the record reductions in HIV incidence in the capital, as well as increased uptake of HIV testing, treatment, and PrEP. The campaign has also been praised for its contribution to tackling stigma, through its consistent promotion of the U=U message (since 2017) alongside condom, testing and PrEP advertising. 

Lessons Learned

Having a consistent approach to HIV across London, despite their being 33 authorities. This was the first London HIV campaign in decades. We ensured a large, consistent presence across public space, with a proven (tested) message for all audiences. By focusing on all audiences, as well as targeted media, we destigmatized HIV and 'put it in the public domain'. We also took the (then, radical) approach of using graphic design, rather than people's faces, in order to reach a wider audience without stigmatizing certain groups by association. Further, in using the latest marketing techniques, tools, metrics, and analytics, through 6 years of campaigns we have been able better to reach our audiences with clearer messaging and targeting, eliminating waste; this is reflected in our evaluation and advertising metrics.  

Conclusion

As stated above - a combination of London's impressive epidemiology, combined with impressive output and outtake data, demonstrating that the program is delivering on its stated mission, aims and objectives.  

Sustainability/Continuity during COVID-19

The campaign was able to deliver on its objectives by fulfilling its mission to deliver a 2020/21 campaign - albeit delayed from July launch to November. The pandemic forced us to rethink how to reach audiences, given the 'stay at home' instruction, but it actually reinforced our 'digital first' strategy which was being developed (based on evaluation metrics from previous campaigns) prior to the pandemic. The 2020 campaign, despite not using billboards or transport network adverts, was actually our MOST effective campaign to date, reaching more people than ever before.  

What has not been able to deliver during the pandemic is the MSM Venue-based outreach, testing and condoms workstream. That service was all but suspended in March 2020 (aside from making free condoms available from the program website by post to gay men). Given the ongoing closure - aside from a brief period from 4 July to 4 November - of gay venues and concerns about face-to-face security in delivering the commissioned service, it was not possible for the provider to deliver services during the pandemic. Negotiations have concluded with the provider to deliver an alternative service once lockdown ends and society reopens. However, the shift online for services such as HIV testing at home would seem to indicate new levels of acceptability and normalization of at-home prevention services. The HIV sector is learning about how this redefines old ways of reaching key communities in London and beyond. 

Contact Information

Name: Aleksandra Mecan
City: London  
Organization: London HIV Prevention Programme (Do It London)
Email: AMecan@lambeth.gov.uk
Phone number: +44 (0) 77 83 850 413 

Best Practice Information

Best Practice Title

Victorian PrEP Accord

Best Practice Type

• Policy

Best Practice Domain

• Finding and testing HIV unawares, especially young men and women
• Meeting the needs of key populations
• Improving health-related quality of life and quality of care 
• Facilitating an effective interface between health services/community services 
• Accelerating uptake of proven interventions/policies/diagnostics/medicines 
• Other – Community Mobilisation 

Best Practice Primary Audience

• Community
• Clinician 
• Researcher/Academia 

Best Practice Description

Introduction

As HIV pre-exposure prophylaxis (PrEP) was being introduced in Australia, there was a need to ensure gay, bisexual, and other men who have sex with men (MSM) were able to access PrEP information supported by both medical and social research. There was a need to challenge misconceptions and stigma associated with PrEP and to further frame sexual health in a way that was both sex positive and inclusive. With PrEP initially introduced through state-based demonstration trials, there was also a need to get PrEP approved by the relevant government authorities and ensure it could be made as accessible as possible in Victoria and across Australia. The primary objective the Victorian PrEP Accord was to establish a set of shared principles around the adoption of PrEP and establish a collaborative partnership between community organisations, grass-roots activists, and medical researchers. 

Description

In 2015, Thorne Harbour Health (then the Victorian AIDS Council), Living Positive Victoria, researchers from the VicPrEP (later PrEPX) clinical trial as well as grassroots groups PrEPaccessNOW (PAN) and PrEP’D for Change signed the Victorian PrEP Accord outlining a set of shared principles around the adoption of PrEP as an important HIV prevention tool. Later, Positive Women Victoria joined the accord as an additional signatory. The accord focused on ensuring gay men and other MSM were able to access PrEP information supported by research and worked to remove barriers in accessing PrEP. This included the expansion of demonstration trials, approval by Australia’s Therapeutic Goods Administration (TGA), approval by Australia’s Pharmaceutical Benefits Advisory Committee (PBAC) for government subsidy, access via the Personal Importation Scheme, and responding to ongoing accessibility needs for at risk populations ineligible for Medicare subsidies). The Victorian PrEP Accord has also worked collaboratively to promote the adoption of PrEP alongside Undetectable Viral Load (UVL) as complementary biomedical HIV prevention strategies.       

Data Collection

N/A

Results, Outputs, and Outcomes

The PrEP Accord facilitated conversations between researchers and MSM, allowing MSM to raise concerns and researchers to test ideas. The PrEP Accord also enabled coordinated advocacy with policy makers and funders. The VicPrEP Study expanded enrolment to become the PrEPX study and went on to become the fastest enrolled PrEP demonstration trial anywhere in the world. Following approval by Australia’s Therapeutic Goods Administration (TGA) in 2016, PrEP was added to Australia’s Pharmaceutical Benefits Scheme (PBS) in 2018 – allowing Australians to access the medication with government subsidy. Additional pathways for PrEP access have been established for people facing financial barriers or are ineligible for government subsidised healthcare and medications including the PrEPaccessNOW PrEP Coupon Scheme pioneering PrEP access via free coupons for those unable to afford PrEP.  

Lessons Learned

Accord partners represented a coalition of community organisations, researchers, and grass roots activism, which positioned the accord for success – ensuring health messaging undertaken by each partner organisation was coordinated with clinical oversight in culturally appropriate language. The formation of the Accord allowed partners to collaborate, such as with the introduction of community grass roots activists becoming formal study partners for PrEPX. The Accord also facilitated collective action in guiding the community discussion about the rollout of PrEP and biomedical prevention more broadly. 

Conclusion

The Melbourne Gay Community Periodic Survey is a cross-sectional survey of gay and homosexually active men throughout Victoria. While the survey has been running annually since 1998, the most recent survey was conducted in January 2020. Over the course of the Vic PrEP Accord (2016-2020), the survey has shown knowledge of PrEP availability increase from 52.2% to 94.7%. Use of PrEP increased from 5.7% to 38.9%. Of the respondents who did not always use condoms, PrEP use by the HIV-negative partner increased from 5.5% to 37.6%. In 2020, 81.9% of participants with casual partners reported HIV prevention coverage or safe sex (i.e., avoiding anal sex, consistent condom use, PrEP, or undetectable viral load), an increase from 69.4% in 2016.  

Furthermore, the effective promotion of PrEP as a biomedical HIV prevention strategy has bolstered community dialogue and acceptance of Undetectable Viral Load (UVL) and the message that Undetectable = Untransmittable (U=U).  

Sustainability/Continuity during COVID-19

The PrEP Accord continues albeit without the urgency that it had prior to PrEP being subsidised and available through prescription. During COVID, when Australian borders were closed, relationships developed through the Accord provided key intelligence on PrEP adherence and allowed for conversations with PrEP users to occur regarding PrEP breaks during lockdown, PrEP on Demand as an alternative recommencement strategy and brief PrEP availability issues. 

Contact Information

Name: Simon Ruth
City: Melbourne  
Organization: Thorne Harbour Health (formerly the Victorian AIDS Council)
Email:  simon.ruth@thorneharbour.org
Phone number: +61 3 9865 6700

Best Practice Information

Best Practice Title

The Undetectables Viral Load Suppression Program 

Best Practice Type

• Intervention

Best Practice Domain

• Promoting early initiation of and adherence to HIV treatment 
• Enhancing retention and long-term engagement in HIV care with viral load suppression 
• Meeting the needs of key populations 
• Improving health-related quality of life and quality of care 
• Addressing disparities in access to/utilization of HIV services 
• Eliminating stigma/discrimination, notably within health settings 

Best Practice Primary Audience

• Community 
• Clinician 
• Health Department or Ministry of Health 
• Implementing Partner 
• Government/Policy Maker 

Best Practice Description

Introduction

Many people living with HIV (PLWH) face barriers to achieving and maintaining viral load suppression (VLS). These barriers can include poverty, food and housing insecurity, behavioral health issues, history of trauma, and mental health symptoms. When PLWH experience one or more of these barriers, it can be hard for them to adhere to their ART regimen and can increase the risk for HIV-related illness as well as viral transmission to others. The Undetectables Viral Load Suppression Program is a client-centered model that employs innovative superhero-themed, anti-stigma social marketing, agency cultural change, and a toolkit of evidence-based ART adherence strategies—including financial incentives—to support adherence and VLS among PLWH with barriers to achieving VLS. The goals of the program are to improve ART adherence, retention in HIV medical care, prompt linkage to social support services, and viral suppression (<200 copies/ml).  

The Undetectables was developed and launched in 2014 by Housing Works, a community-based organization in New York City, as a two-year demonstration project funded by the Robin Hood Foundation. Encouraged by preliminary findings from the demonstration project (see Results, Outputs, Outcomes below), the New York City Department of Health and Mental Hygiene (NYC Health Department) and Housing Works convened stakeholders in mid-2015 to explore program scale-up. Beginning in 2016, the NYC Health Department contracted with seven agencies (five FQHCs and community health centers, one hospital, and one hospital/CBO partnership) to implement The Undetectables in 20 different sites across NYC.  

Description

The Undetectables is intended to be integrated into agency operations and existing HIV care management programs (e.g., Ryan White-funded Medical Case Management programs, Medicaid Health Homes, etc.). The NYC Health Department required agencies to either provide both HIV medical services and HIV care management or establish a partnership between an agency providing HIV care management and an HIV medical care provider. Agencies must complete an organizational readiness assessment and develop an implementation plan based on the assessment prior to program implementation.  

The Undetectables Program is comprised of three main components: the social marketing campaign to engage clients, staff, and the community; agency culture change to elevate VLS as a key goal across the organization; and an evidence-based toolkit for medication adherence. The social marketing campaign features a group of superheroes known as The Undetectables. They highlight how being undetectable improves individual and community health and well-being, making the individual a hero in combating the HIV epidemic. The campaign emphasizes the importance of maintaining an undetectable viral load to prevent HIV transmission to sexual partners, a message known as Undetectable = Untransmittable (U=U). The characters battle villains such as apathy, denial, fear, and stigma. These characters are brought to life in a comic book series and a variety of print and digital materials that agencies are encouraged to post on their social medica platforms, as well as in their brick-and-mortar locations. The agency culture change starts with an organizational readiness assessment accompanied by ongoing technical assistance provided by Housing Works. Support from senior staff is key for successful implementation, but information and training sessions are provided for all staff. The social marketing materials contribute to agency culture change by engaging staff and clients.  

Other activities like program launch events or Undetectables-themed health fairs promote the program and excite clients and staff alike. The Undetectables toolkit includes a variety of evidence-based adherence support strategies including client-centered case conferencing and care planning; motivational interviewing-based adherence counseling; adherence support groups; devices such as pill-boxes and timers; directly observed therapy; and quarterly $100 unrestricted gift cards for lab results showing a viral load <200 copies/ml. Clinicians, care managers, and clients collaboratively develop a care plan that includes the adherence support strategies that will best serve the client. The toolkit is variable to accommodate different client needs and agency capacities, with the core components—case conferencing (ideally with the client present), client-centered care planning, and financial incentives for VLS—being required for all clients. For more information on The Undetectables VLS Program, please visit www.liveundetectable.org. 

Data Collection

The NYC Health Department requires funded agencies to collect background, service utilization, and outcome data for all clients enrolled in the program. An initial assessment of sociodemographic and psychosocial characteristics (e.g., housing, food security), mental health and substance use history, and HIV outcomes (e.g., VLS status) is conducted when a client enrolls. A reassessment is completed every six months throughout the client’s participation to monitor progress over time. Service utilization data, including receipt of HIV care management services, distribution of financial incentives, and viral load (VL) laboratory values, are routinely collected. All this information is entered into a secured, web-based system for reporting services funded by the NYC Health Department.  

Quality indicators for The Undetectables Program are:  

• Viral Load Suppression and Labs o % of clients virtually suppressed at time of program enrollment  
  • % of clients virally suppressed at 30-90 days and ≥90 days after enrollment, stratified by suppression status at the time of program enrollment  
  • % of clients who had at least one viral load reported during the quarter  
  • % of clients engaged in care (defined as having ≥2 VL labs at least 90 days apart from each other) who are virally suppressed  
  • % of clients engaged in care with evidence of durable VLS (defined as having no unsuppressed viral loads [≥200 copies/mL] within a 12-month period)  

• Incentive Distribution  
  • % of clients who received an incentive during the quarter o % of clients who had documented VLS for each incentive (overall and by # of incentives received)  

• Service Utilization  
  • % of clients who had an initial case conference withing 45 days of enrollment  
  • % of clients who had a care plan service within 45 days of enrollment  
  • % of clients with ≥1 unsuppressed VL who had at least one case conference or care plan ≤45 days after the date of the unsuppressed lab  
  • % clients due for a reassessment who have completed one  

• Client Characteristics  
  • % newly enrolled clients who meet at least one of the program eligibility criteria  
  • % newly enrolled clients who met each of the program eligibility criteria (presented separately) 

Results, Outputs, and Outcomes

Housing Works collaborated with the University of Pennsylvania to develop, implement, and evaluate The Undetectables VLS Program demonstration project. The 24-month demonstration project was conducted from 2014 to 2016 to examine the impact of the intervention among a sample of 502 Housing Works clients who experienced a range of barriers to ART adherence, including high rates of mental illness, substance use, and homelessness.  

Initial evaluation findings indicated significant positive impact on time spent virally suppressed (<200 copies/mL) found in pre/post evaluation including a 15% increase post intervention in mean proportion of all time points undetectable, from 67% to 82% (17% increase using <50 copies/mL) and a 23% increase post-intervention in proportion of clients virally suppressed at all time points assessed, from 39% to 62% (20% increase using <50 copies/mL). Additionally, point-in-time viral suppression increased from 68% at baseline to 85%. Qualitative results indicate that the intervention increased ART adherence by attaching worth to viral suppression, promoting engagement in support services, and increasing motivation to achieve and maintain suppression. 

Based on the promising results from Housing Works’ demonstration project, the NYC Health Department funded a citywide scale-up of The Undetectables Program as part of the Ending the Epidemic initiative in New York State. Since citywide implementation began in 2017, over 2,900 individuals have been enrolled in The Undetectables at seven contracted agencies. As of December 31, 2019, among enrolled clients engaged in care (n=2,311), 88.7% were virally suppressed at their most recent lab. Among clients enrolled for the entire 2018-2019 grant year (n=1,185), 76.7% demonstrated evidence of durable VLS. Further evaluation of the program is planned by the NYC Health Department in order to compare VLS and durable VLS rates among Undetectables clients with rates among clients enrolled in care management programs that do not provide the financial incentives. 

Lessons Learned

Supportive policies at the state and local level greatly facilitated the citywide scale-up of The Undetectables. The New York State Ending the Epidemic (ETE) Blueprint, which was released in 2015, includes a specific recommendation to incentivize patients for achieving and maintaining VLS. In December 2015, NYC announced a VLS Learning Lab Consortium to develop a scalable model of The Undetectables as well as ETE funding for implementation by seven contracted agencies. Housing Works was contracted as the technical assistance provider and continues to provide training and technical assistance. Stakeholders buy-in and participation played a key role in the success of the citywide scale-up. The VLS Learning Lab Consortium—comprised of medical directors, HIV program directors (hospitals and CBOs), Medicaid HIV Special Needs Plan program staff, and subject matter experts—led five work groups focused on  

1) identifying the essential elements of the program, providing the evidence base for every element, and developing guidelines on best practices; 

2) creating an organizational readiness checklist and developing the curriculum, including a five-part training series; 

3) adapting social marketing for a broader audience;  

4) identifying strategies for sustained funding;  

5) monitoring and evaluation.  

Private foundation funding also supported both the development of the intervention and scale-up activities. In addition to Robin Hood Foundation funding for the two-year Housing Works Undetectables demonstration project and evaluation, Housing Works also received funding from the New York State Health Foundation Special Projects Fund to provide support for its work on scale-up preparation. Implementation successes include:  

• Geographic coverage in areas of NYC with high HIV prevalence; 
• Reaching PLWH who experience barriers to adherence, particularly poverty (reported by 83% of participants as of December 2019), food insufficiency (39%), and unstable housing (31%);  
• Scaling up the program in various settings across NYC, including CBOs, community health centers, hospitals, and CBO/hospital partnerships;  
• Identifying essential vs. recommended elements of the model to allow for integration into a range of existing HIV care management programs;  
• High degree of fidelity to essential components of the model; and  
• Setting an example for a successful collaboration between local government and a CBO partner to bring a promising intervention to scale. 

Additionally, quarterly roundtables and ongoing learning collaborative meetings mean that there is ample opportunity to hear feedback from the agencies and for agencies to learn from each other to best implement the program. The program can be responsive to ever-changing agency needs because of the flexibility of the funding source. Integrating the model into a range of existing HIV care management programs is an ongoing challenge as each program has its own forms and requirements; however, the NYC Health Department has tried to make The Undetectables model as flexible as possible while maintaining the integrity of the program. Processes and protocols have been streamlined where possible, but often there are staff buy-in and operational challenges, like disparate data reporting systems.  

The program can also be limited by an agency’s existing HIV care management program capacity. Several lessons were learned about the use of financial incentives to promote VLS during the development and scale-up of The Undetectables. First, existing literature underscores the importance of packaging financial incentives with other evidence-based strategies to support medication adherence, such as patient education as well as individualized adherence planning and counseling. Second, incentive structure (e.g., frequency, value) should be determined using existing research, clinical experience, and community input. Lastly, programs that provide financial incentives should be targeted to individuals who experience demonstrated barriers to adherence, including individuals who are virally suppressed but continue to face ongoing barriers. 

Conclusion

When clients take ART regularly and achieve durable VLS, they are much more likely to achieve positive health outcomes, and they have no risk of transmitting HIV to sexual partners. This program addresses evidence-based barriers to adherence at an individual, interpersonal, and organizational level and can transform not only individuals but agency culture in order to help the highest-need clients attain and sustain viral load suppression.  

Sustainability/Continuity during COVID-19

During the COVID-19 pandemic, many agencies were concerned about immunocompromised patients and realized that now more than ever, financial incentives could be imperative to client’s health outcomes. Agencies pivoted to telehealth, but most clients needed to come into a site to receive their financial incentive. Mailing gift cards was considered but not adopted because of concerns about losing gift cards in the mail, reaching clients without a permanent address, and clients living with others who may not know their HIV status. Agencies each figured out the method of distributing incentives that worked best for their operations. Some agencies found it was best to have specific days of the week for clients to come in for incentive distribution, especially for those with multiple locations, while others authorized more staff to distribute gift cards, allowing clients to come in whenever it fit their schedule best. Additionally, other means of distributing financial incentives are being explored now, the most promising of which would be a reloadable gift card so an individual would not need to come in person to receive their incentive. 

Contact Information

Name: Grace Herndon; Gina Gambone; Naomi Harris Tolson
City: New York City  
Organization: NYC DOHMH and Housing Works
Email: gherndon@health.nyc.gov; ggambone1@health.nyc.gov; nharristolson@housingworks.org 
Phone number: -

Best Practice Information

Best Practice Title

"Au labo sans ordo ": An 18-month local experimentation of free HIV testing without prescription in private biological laboratories in Paris and the Alpes-Maritimes 

Best Practice Type

• Intervention

Best Practice Domain

• Finding and testing HIV unawares, especially young men and women 
• Linkage to HIV care and support services 
• Promoting early initiation of and adherence to HIV treatment 
• Meeting the needs of key populations 
• Accelerating uptake of proven interventions/policies/diagnostics/medicines 

Best Practice Primary Audience

• Community 
• Clinician 
• Other: Medical laboratories clientele and key populations notably newcomer migrants from sub-Saharan Africa and young MSM.

Best Practice Description

Introduction

Screening is the entry point to care but remains the weak point in the HIV care cascade in France, despite progress in terms of recommendations and diversification of services. Considering that, the insufficient increase in laboratory testing and the overload of community-based and public free STIs screening centers (on which screening in France is based and which allowed for 5.8 million tests to be performed in 2018) will not contribute to the necessary testing scaling-up targeted at key populations needed to change the HIV incidence curve. The population affected by this situation are sub-Saharan migrants and MSM, particularly at risk for HIV. The objectives of the intervention were to offer free HIV screening, available in all medical laboratories, without prior physician appointment or prescription needed, coupled with a targeted communication campaign will remove obstacle in resorting to testing and significantly increase the screening coverage in the city. 

Description

The intervention was piloted for 18 months starting from January 2019 in every Paris and the Alpes-Maritimes’s medical laboratory (157 and 106 laboratories respectively). The health offer was open to anyone with health insurance over the age of 18 (including State Medical Care for undocumented migrants) regardless of where they live in the region, and also to uninsured persons. Immediate appointment for care through an ad-hoc navigation platform provided by the regional hospital-based HIV coordination was offered to those who received an HIV+ diagnosis. The intervention was implemented with the help of the national health insurance fund and local public health authorities, regional representatives of medical biology, local administrative authorities and AIDS-free cities carrying the project (“Vers Paris sans sida” and “Objectif sida Zéro” in Nice). 

Data Collection

The data and indicators were collected throughout the 18 months and the following were measured/analyzed:  

• Measuring the activity of the intervention and its contribution to the overall HIV screening carried out in the laboratories;  
• Measuring the impact of the offer on the activity of the laboratories in relation to the activity of free STIs screening centers;  
• Describing the profile of users of this new offer in comparison to the profile of the people who have been tested for HIV in the laboratories with a prescription and/or people tested in free STIs screening centers (a questionnaire survey among the users of the various offers was conducted twice during the 18 months);  
• Describing the people diagnosed HIV positive via the offer and documenting their linkage to care and treatment initiation (authorization to document the linkage was asked of the individuals);  
• Collecting the appreciation and feedback of biologists on the implementation of the new offer;  
• Comparing the testing costs among the 3 possibilities: the new offer (in a laboratory without prescription), in a laboratory with prescription, in a dedicated HIV testing facility.  

Results, Outputs, and Outcomes

• In terms of testing volumes, the offer represents + 7.2% (+ 8,1% during 2019 2nd semester; +7,0% and +6,2% during the 1st and 2nd semester of 2020 respectively) of overall laboratories HIV screening activity between July 2019 and December 2020, with +32,652 tests performed in Paris and 12,086 tests in the Alpes-Maritimes department. Compared to the 2nd half of 2018 taken as reference for the increase in screening in "normal" periods the offer allowed for a significant increase in screening in the second half of 2019 of +16.4% men and +7.1% women in Paris. The offer benefited men more than women and is therefore very different from prescription tests. Also, young people aged 18 to 24 and people aged 45 to 54 made the most use of the offer. Despite the impact of the covid-19 pandemic, the positivity rate within the offer stayed higher than the rate of prescribed tests (2.4 per 1000 vs 2.2 per 1000 for prescribed tests). 
• 30 over the 101 people found HIV positive in both territories during the intervention gave permission to document their linkage to care. Among those 30, 5 already knew their status and navigation allowed them to return to care. For the 29 patients whose mode of transmission was documented, 86% belonged to populations at high risk of exposure to HIV (MSM and/or sub-Saharan Africa-born heterosexuals). The median duration between diagnosis and first appointment to care is 5 days, which is better in comparison to that of patients diagnosed in the classical screening offers and provides individualized support for care. This systematization of support towards care via navigation also made it possible to guarantee the completeness of mandatory declarations and facilitate the rapid implementation of therapeutic management and coordinated multidisciplinary management of the patient. Navigation for the offer has facilitated the care pathway and enabled effective networking between healthcare professionals.  
• The offer appealed to a distinct audience in comparison with the public getting tested with prescription or in free STIs screening centers. Compared to people getting tested with prescription, those who used the offer were mostly heterosexual men, people exposed to HIV, people with multiple partners or who have already feared infection, and populations that are more distant from the health care system. The offer also appeared to be an opportunity to come to the laboratory for other tests (30% of those tested in 2020). The users of the new testing system are different from free STIs screening centers users who are younger, more often born abroad with a lower socio-economic level and a higher exposure to HIV. People who are tested for HIV for the first time are more likely to turn to free STIs screening centers. The different HIV testing offers respond to different social and exposure contexts with the new offer, meeting the other two options halfway. The main strength of the new offer is to attract and retain heterosexual men, a group that is more distant from care and in which the incidence of HIV is low but the median to HIV diagnosis is over 4 years.  
• The survey conducted among biologists showed that the management of this new offer did not weigh on the everyday functioning of the laboratories. They considered the offer to be attractive for their clientele and repositions them in their role as public health actors. More than half of the biologists see the navigation service as an advantage for linkage to care. Almost all of them would like to see the intervention become permanent and half would like to see the offer extended to all STIs and viral hepatitis.  
• The main objective of the cost study is to evaluate and compare the cost of the new offer with testing with prescription in laboratory, testing in a free STIs testing center, community, and associations testing, in relation to the effectiveness (and user profiles). The aim is to estimate the average cost per negative test vs the average cost per positive test which can be considered as a proxy for the management of care of people diagnosed with HIV. The results are not yet available as they are expected for the end of June 2021. 

Lessons Learned

What worked well and facilitated the implementation of this intervention was the association from the start of all the public authorities, and in particular of the health insurance fund and the representatives of the biology profession, which enabled us to obtain the support of the laboratories. In addition, the launch of the intervention was backed up by a dedicated communication campaign designed to remove disincentives to testing by promoting the advantages of the offer for users, i.e., its accessibility to all, without prescription, without appointment, free of charge and its availability in all laboratories in Paris and in the Alpes-Maritimes.  

The difficulty was the time spent by the biologists to transmit monthly data on their HIV activities and the new screening offer. For the laboratories, HIV tests represent only a small part of their global activity for which they do not devote specific time. Asking them to set up this monthly routine proved to be very difficult and time consuming, especially with the arrival of COVID-19 in the middle of the intervention. Nonetheless, we were able to collect the necessary data to evaluate the intervention, even if they were not complete. 

Conclusion

The results of the evaluation of this intervention were submitted to the national health insurance fund to inform its decision to perpetuate and extend the offer to the whole country, so that as many people as possible can benefit from this facilitated access to HIV laboratory testing. This intervention is considered a "best practice" because it has enabled the coordination of public authorities and public health actors on a local scale to propose an innovation in sexual health that can now live as a common law health service. The program was also a solution that all health professionals relied on to encourage patients not to postpone a test when dedicated structures or laboratories were clogged for various reasons, particularly during the pandemic. 

Sustainability/Continuity during COVID-19

The results of the evaluation of this intervention were submitted to the national health insurance fund to inform its decision to perpetuate and extend the offer to the whole country, so that as many people as possible can benefit from this facilitated access to HIV laboratory testing. This intervention is considered a "best practice" because it has enabled the coordination of public authorities and public health actors on a local scale to propose an innovation in sexual health that can now live as a common law health service. The program was also a solution that all health professionals relied on to encourage patients not to postpone a test when dedicated structures or laboratories were clogged for various reasons, particularly during the pandemic. 

Contact Information

Name: Pamela Ngoh
City: Paris
Organization: Vers Paris sans sida
Email: projets.sante@parissanssida.fr
Phone number: +33 7 87 84 03 53

Best Practice Information

Best Practice Title

“Dr. Naked”- Communication Strategy for MSM and LGBTQI+  

Best Practice Type

• Strategy / Guidelines 

Best Practice Domain

• Meeting the needs of key populations 
• Other: Creating content related to sexual health, reproductive health and risk reduction towards young MSM and queer people.

Best Practice Primary Audience

• Community 

Best Practice Description

Introduction

Young MSM as well as many subsections of the LGBTQI+ community tend to stay away from the health care system and general health prevention messages which they do not feel are directed at them, since they are very visible in society in general. The objectives of the communication strategy targeting these communities is to empower them to take charge of their own health and adopt appropriate preventive behaviors by using their specific ways of communication. 

Description

The main action carried out is the creation of contents and animation of the Instagram "Dr. Naked" to inform the community about the good plans in matters of prevention and testing around them and interact with the community. This communication strategy also aims to acquire new subscribers on our pages, so that our messages have the greatest possible reach. All the work is implemented by the communication and community manager at Vers Paris sans sida.  

Hence, the accounts’ editorial calendar has been designed to fit with the major themes such as testing, PrEP, self-worth (mental health) and consent. To ensure that our messages match the expectations of the target, partnerships are set up with community associations, collectives and prominent figures and influencers. 

Data Collection

The data collected by the social media activity are: the number of new subscribers on the accounts and the key point investigators generated by the posts. 

Results, Outputs, and Outcomes

• For example, in terms of audience growth on the Instagram page "Dr naked", at the beginning of 2020, the 4000 subscribers were made up of 30% of 35-44 yo and 25% of 25-34 yo. Today, the account reaches 12,300 people who are aged 18-24 yo (25%), 25-34 (40%). Thanks to the collabs with influencers and to sponsorship, the key points indicators of some of the account's posts show up to 2000 likes and over 30,000 impressions, which are great results considering this is a sexual health account with a brand-new strategy. 

Lessons Learned

The new strategy of rejuvenating the account's MSM target and creating content that speaks to all sub-sections of the LGBTQI+ community has paid off in terms of the impact. working in partnership with community groups and influencers has been beneficial in implementing the strategy and creating content that is relevant to the LGBTQI+ community. 

Conclusion

The growing traffic on the account allows the community to find specific sexual health information that meets their expectations. This strategy is considered a best practice because it has adapted the communication codes inherent to the MSM and LGBTQI+ communities to bring targeted sexual health information to them when general population communications did not specifically try to reach them. 

Sustainability/Continuity during COVID-19

The Instagram account has proven to be a very useful tool for the community since the Covid-19 pandemic started and especially during the successive lockdowns and curfew periods that the country has experienced since. In addition to providing valuable and practical information on access to testing and diversified prevention in the context of the health crisis, it has also allowed its subscribers and the LGBTQI+ community at large to stay connected and socialize especially during the 1st lockdown which was very hard and isolating. 

Contact Information

Name: Pamela Ngoh
City: Paris
Organization: Vers Paris sans sida
Email: projets.sante@parissanssida.fr
Phone number: +33 7 87 84 03 53

Best Practice Information

Best Practice Title

Initiative to Reduce the Vulnerabilities of LGBTQIA + Populations and People Living with HIV/AIDS Facing the COVID-19 Pandemic 

Best Practice Type

• Intervention

Best Practice Domain

• Finding and testing HIV unawares 
• Especially young men and women 
• Promoting early initiation of and adherence to HIV treatment 
• Meeting the needs of key populations 
• Addressing disparities in access to/utilization of HIV services 
• Other (The COVID-19 pandemic had as a consequence: difficulty in accessing ARV treatment, attending consultations and socioeconomic consequences for PIVHIV. Therefore, it was also necessary to offer basic, hygiene and prevention baskets to COVID-19). 

Best Practice Primary Audience

• Community 
• Health Department or Ministry of Health 
• Government/Policy Maker 
• Donor 

Best Practice Description

Introduction

The rise in unemployment, lack of food, lack of PPE and supplies for the prevention of COVID-19 and STIs has caused a significant increase in vulnerability among the LGBTQIA + population.  Many People Living with HIV/AIDS (PLHIV) abandon their treatments or do not initiate treatment because they do not have access to health services or –antiretrovirals (ARVs).

The LGBTQIA + population is already well known for facing recurrent prejudices that make them economically vulnerable due to homophobia/transphobia. It should be noted that the LGBTIQA + population is also the most vulnerable to Sexually Transmitted Infections (STIs), including HIV / AIDS. From 2009 to 2018, the STD / AIDS Program of the Municipality of São Paulo notified 28,888 people with HIV, 23,110 (80%) men, mostly in the 15 to 29 age group. Of these, 15,802 (54.7%) were MSM or bisexual (Municipal Coordination of STD / AIDS of São Paulo, 2019). The incidence of STIs is higher among transgender women.

Instituto Cultural Barong is a Non-Governmental Organization (NGO) promoting sexual and reproductive health and fighting STIs / HIV / AIDS for over 25 years. Since its foundation, Barong has been developing field programs, also called extra-walls, to work in places where LGBTQIA + people work or play, strengthening their dialogue with this audience through their communication strategies, promoting sexual health education and reproductive health as well as providing guidance on their social rights. Simultaneously, Barong acts strongly with the population living with HIV / AIDS, promoting adherence to health services, the use of medicines, and the prevention and the reduction of vulnerabilities.

Due to the COVID-19 pandemic, between March 27 and 31, 2020, UNAIDS-Brazil conducted an initial primary survey with 3,000 people from the LGBTQIA + community several of who are living with HIV. The survey observed the extreme vulnerability of this population, as well as identified their basic needs for food and hygiene. Based on this research, Barong worked with UNAIDS-Brazil to define the development and implementation of the “Projeto Balaio” - health, inclusion, and community, which is funded by UNAIDS-Brazil,  AIDS Healthcare Foundation, and physical donations, which totalled 1,600 food baskets delivered, 1,200 kg hygiene and cleaning baskets, 1,200 STI / AIDS prevention kits, 1200 COVID-19 protection kits, delivery of gas loads, sending of medicines by national and international mail, in addition to clothes, shoes, blankets, prescription glasses, crutches in case of special needs, among other items.

Description

At first, the project was implemented to meet the needs of the LGBTQIA + population through the distribution of basic food baskets, hygiene baskets, and COVID-19 and STI prevention kits.  The project demonstrated that it is necessary to deliver basic needs to peoples’ homes, as they are unable to attend scheduled places and times.

Further on, the project identified that several PLHIV were abandoning their treatments because they were unable to physically go to health services to receive antiretroviral drugs. Therefore, Project Balaio received the institutional support of CRT DST / AIDS / SP, the Outpatient Clinic for Integral Health of Transvestites and Transsexuals, the Emílio Ribas Hospital, CRD, and the NGO Pela Vidda to delivery lifesaving ART. Additionally, in partnership with CRT DST / AIDS / SP, health professionals who monitor the process of hormone therapy for transgender people supported us in sending hormone therapy medicines to transgender populations needing it. In those cases where the mail cannot achieve as well as some invasion sites, communities and settlements, Barong delivers the medicines personally, with his support car. Even so, many times before the delivery itself, it is necessary to "agree" with the head of the local faction, the consent for the delivery of the medicines.  

Data Collection

The project is ongoing, and we are collecting data on race, occupation, income, age, whether it is being treated or not, costs of sending medicines, food baskets, hygiene, and others. We anticipate that the cost to date has exceeded $40,000.00 obtained from donors such as AHF, UNAIDS and UNESCO and personal donations.    

Results, Outputs, and Outcomes

As stated above, the project is in progress. Given this was the first time in Brazil that medicines have been delivered through an NGO in partnership with public sector, we addressed and put processes in place for several issues such as authorizations of treatment, shipping, and patient confidentiality. The number of orders sending medicines has grown, since the COVID-19 pandemic in Brazil. Barong will absorb other services to serve more PLHIV. When the pandemic is over, we intend to continue sending medicines to those people who live in other cities and are forced to travel to collect the medicines, and often lose many a day's work or assume financial expenses that can be minimized through this project. Facilitating access to medicines can be another strategy to ensure PLHIV remain on treatment.

Lessons Learned

The project is going well, our biggest difficulties are logistical and financial, São Paulo is a big city and requests for basic food and hygiene items come from everywhere. Although we have divided delivery by regions, we require more resources to reach the most distant regions. Some people often did not have money for the bus to reach the meeting point. In these cases, when this need was expressed, we paid for transportation. Mail also does not deliver to areas at risk (periphery, traffic points), in this case, we negotiated with the local authorities and went personally to deliver the medicines. However, this is only possible in the city of São Paulo. Should any cases arise in another state, it will be necessary to identify partner NGOs.   

Conclusion

There is no doubt that many people only followed up with their treatments and consultations because of this project. The active search carried out by the services - São Paulo State AIDS Program and Hospital Emílio Ribas identifying those who were out of medicine and sent case by case to Barong demonstrated once again the strength of the partnerships. The delivery of basic food and hygiene baskets also brought us closer to the transgender populations so that after the COVID-19 crisis, we can carry out other (non-welfare) projects with this population. Facilitating ARV access via NGOs in a continental country like Brazil, can ensure continuity of treatment and establish links between PLHIV and NGOs.

Sustainability/Continuity during COVID-19

Barong is concerned and considers the socioeconomic vulnerability of several Brazilian people and refugees motivates the continuity of all these actions, after all, the outlook for these excluded populations is certainly not promising for this year either. The cohesion between the prevention of COVID-19 associated with the real demands of everyday life intensifies this differentiated and individual look for the LGBTQIA + and PLHIV populations, so that they are not exposed to more difficulties than those they already face.

The results were considered so relevant that the project to send medicines to the LGBTQI+ population in a context of vulnerability acquired new supporters for its continuity and expansion in 2022, regardless of the context of COVID-19.

Contact Information

Name: Marta MC Britton
City: São Paulo
Organization: Instituto Cultural Barong
Email: martamcbritton@gmail.com
Phone number: +11976941329

Best Practice Information

Best Practice Title

Bloomsbury Peer Support Team as the first example of paid peer support and a gold standard newly diagnosed course co-facilitated with the Bloomsbury Patient Network that is relevant to 2nd, 3rd and '4th’ 90s 

Best Practice Type

• Intervention

Best Practice Domain

• Linkage to HIV care and support services 
• Promoting early initiation of and adherence to HIV treatment 
• Enhancing retention and long-term engagement in HIV care with viral load suppression 
• Improving health-related quality of life and quality of care 
• Facilitating an effective interface between health services/community services 
• Eliminating stigma/discrimination, notably within health settings 

Best Practice Primary Audience

• Community 
• Clinician

Best Practice Description

Introduction

We offer peer support to patients registered with the Bloomsbury Clinic at the Mortimer Market Centre. Our team is part of the peer support workforce within Central North West London NHS Foundation Trust across mental health, addiction, and HIV services. We offer patients the opportunity to meet another person living with HIV, and by doing so we hope to challenge barriers created by stigma. And by exchanging our lived experiences, we aim to equip patients to live healthier and happier lives. We support patients who are newly diagnosed and who live with HIV long-term. We offer a listening ear and support patients to take control over their diagnosis through role modelling and empowering them with practical and useful knowledge about medical and social aspects of living with HIV. We also co-facilitate with the Bloomsbury Patient Network the Newly Diagnosed Course, which is open to anyone living with HIV, who have just been diagnosed or living with HIV for longer but have not adjust to their diagnosis. 

Description

We offer a listening ear, and we signpost or refer to HIV charities and other NGOs. Internally, we refer patients to other services provided by our clinic, namely Health Advisers and psychology. We co-facilitate a Newly Diagnosed Course quarterly with the Bloomsbury Patients Network, and a lecture for medical students on Living with HIV, in partnership with our inhouse psychology team. We are shadowed by new members of staff during their induction and student nurses on their placements, helping to raise awareness to the social aspects of living with HIV and the importance of providing peer support services within healthcare settings.  

Data Collection

Starting in 2020, we audit our Peer Support interventions, which we submitted via email. 

Results, Outputs, and Outcomes

While we do not actively collect feedback from patients, but patients often give feedback on our peer support interventions to their consultants and other clinic staff, which is then shared with us. This year we audited our interventions, looking at types of peer support interventions and demographics, which we shared with our colleagues working in HIV and mental health services. The aim is to carry out this exercise yearly. Additional information can be found in the SPSW in CNWL HIV power point presentation included below.   

Lessons Learned

What works well and facilitates our work is the fact that peer support is well established and imbedded in our clinic, and well regarded by our clinicians, which makes recruiting patients easy. For some patients, stigma is the main obstacle as they resist meeting another person living with HIV. Other patients find it difficult to relate to their peers’ lived experiences, because they don’t feel represented in those and are unable to focus on the things we have in common rather than the things we differ. 

Conclusion

Peer Support within HIV services in our trust was firstly setup in 1999 as a voluntary position and then as a paid position in 2002. Therefore, the service is well-established and cherished by both patients and clinicians. Peer Support has to be seen within the context of patient centered care, which aims to treat people holistically, as healthcare is much more than prescribing treatment and monitoring long-term conditions. As mentioned before, Peer Support is both a discipline and a sought-after therapeutic tool that is currently used across the globe, in different healthcare settings like mental health, cancer, epilepsy and addiction just to name a few. 

Sustainability/Continuity during COVID-19

As the peer support team still works in loco, during lockdowns, patients can decide if they want to see a member of the team face to face or virtually. We suspended our Newly Diagnosed Course due to social distancing guidelines. We carried out an over the phone consultation to assess if our patients would be interested in attending the course online. The majority told us they would not attend a virtual Newly Diagnosed Course because they were concerned with confidentiality. Others had issues accessing the right tech due to digital poverty or lack of IT skills. 

Supplemental Tools and Resources

• SPSW in CNWL HIV services presentation

Contact Information

Name: Fernando Monteiro
City: London
Organization: Bloomsbury Clinic, Mortimer Market Centre, CNWL Foundation Trust
Email: fernando.monteiro@nhs.net
Phone number: +44 (0)203 317 5177

Best Practice Information

Best Practice Title

Bimbingan Teknis Melalui WhatsApp (BMW) : Utilization Of WhatsApp In Jakarta In Operationalizing Policy, Mobilizing Provider Engagement And Ensuring Service Quality During Covid-19

Best Practice Type

• Strategy / Guidelines
• Intervention

Best Practice Domain

• Enhancing retention and long-term engagement in HIV care with viral load suppression
• Addressing disparities in access to/utilization of HIV services
• Facilitating an effective interface between health services/community services
• Linkage to HIV care and support services
• Accelerating uptake of proven interventions/policies/diagnostics/medicines

Best Practice Primary Audience

• Community 
• Clinician
• Government/Policy Maker

Best Practice Description

Introduction

Social media technologies offer promising channels for operationalising emergency guidelines, engaging health providers, and ensuring service quality where COVID-19 lockdowns, quarantines, and physical distancing restrictions are in effect. The Provincial Health Office (PHO) is working with the USAID and PEPFAR-supported LINKAGES project to introduce weekly WhatsApp (WA) technical assistance (TA) sessions for all HIV health care workers in Jakarta, Indonesia.

Description

The use of WhatsApp (WA) for health professional education is affordable, familiar, and convenient, fostering peer-to-peer based learning across a variety of mobile operating systems. In March 2020, the PHO and LINKAGES held the first Bimtek Melalui WhatsApp (BMW) TA session for Jakarta HIV health care workers, replacing face-to-face quality assurance and mentoring visits during the #StayAtHome period. Subsequent BMW sessions issued emergency guidance, incorporated programmatic promotional messages and instituted feedback mechanisms to gauge utilization of interventions and monitor human resources for health.

Data Collection

Number of sessions conducted, number of participants engaged, and impact towards HIV service delivery.

Results, Outputs, and Outcomes

Five BMW sessions have now been offered on topics such as ART adherence, multi-month dispensing, and ARV home delivery. Ninety-eight percent of 244 participants engaged with the content within one week of posting. Following BMW sessions, 2-month ARV dispensing rose by 533% to cover 7,420 PLHIV and 84 facilities provided home-based ARV delivery to 1,726 PLHIV. Human resource monitoring illustrated that 12% of health care personnel had been exposed to COVID-19 and/or were under surveillance.   

Lessons Learned

WhatsApp can be use as an important social media tool that can help HIV programmers protect the gains made in the HIV response during COVID-19.

Conclusion

Contact Information

Name: Annisa Zakiroh
City: Jakarta
Organization: Linkages - FHI 360
Email: azakiroh@fhi360.org

Best Practice Information

Best Practice Title

Devising A Contingency Plan In Lagos To Avert Covid-19 Impact On The City’s HIV and AIDS Response

Best Practice Type

• Strategy / Guidelines
• Intervention

Best Practice Domain

• • Meeting the needs of key populations
  • Enhancing retention and long-term engagement in HIV care with viral load suppression
  • Addressing disparities in access to/utilization of HIV services
  • Facilitating an effective interface between health services/community services
  • Linkage to HIV care and support services
  • Improving health-related quality of life and quality of care
  • Accelerating uptake of proven interventions/policies/diagnostics/medicines

Best Practice Primary Audience

• Donor
• Community
• Government/Policy Maker
• Health Department or Ministry of Health
• Implementing Partner

Best Practice Description

Introduction

Lagos has a HIV prevalence of 1.4% with an estimated 138,765 persons living with HIV (PLWH), and 116,937 are on treatment as at the end of 2021. The city confirmed its index case of Coronavirus (COVID-19) on 27th February 2020 and has continued to see an exponential increase in the number of confirmed cases since then. In order to curb the spread of COVID-19, the city’s HIV & AIDS program implementation was disrupted.

Description

Averting the challenges posed by COVID-19 is critical to the success of the city’s HIV and AIDS response. As part of its efforts to coordinate the State’s HIV response amidst the pandemic, the Lagos state AIDS Control Agency (LSACA) collaborated with members of the state HIV Consortium to develop a HIV/COVID-19 Contingency Plan.

Prior to the lockdown, as part of the contingency plan, Health facilities and 180 Community Pharmacies were stocked up with Antiretroviral (ARV) drugs for ease of refill for clients using the Hub and Spoke Model. The community pharmacies served as spokes while the health facilities served as Hubs. HIV clients with less than two (2) weeks drugs were actively tracked and recalled for drug refills at the pharmacies nearest to them. The multi-month drugs refill strategy (2-3 months drug refill) was adopted during the period to minimise clients visit to the hospital and ultimately reduce their exposure to COVID-19. This also prevented client’s drug stock out during lockdown to counteract poor drug adherence.

For the key populations with over 24,000 individuals currently on treatment as of March 2020, NGOs were engaged for ARV drug transport to client’s homes and neighbourhoods as applicable to each client. Viral load sample collection from eligible clients was done through the dry blood spot (DBS) method, while samples were transported to the PCR centres in the city for testing.

In the bid to sustain the HIV response in the city during the COVID-19 outbreak and as outlined in line with the contingency plan, emergency relief support was provided to essential health service providers working to roll out the contingency plan. These included, personal protective equipment for the HIV health care providers at facilities and community pharmacies; and psychosocial support to address the mental health issues associated with the COVID-19 pandemic for service providers.

Data Collection

Routine programmatic data from state owned facilities and implementing partners supporting the response in the city was used. The community pharmacies documented ARV refills using the national ARV client monitoring tools and registers. The data was reported to the Hub health facilities for updates to the clients’ records.

Results, Outputs, and Outcomes

Lessons Learned

Community ART programs and support structures played a significant role in sustaining clients ARV refill, Clinical monitoring, and drug adherence during the COVID-19 lockdown. Stable clients still get their medicines (post lockdown period) from community pharmacies. Courier services still deliver medicines to KP client’s doorsteps in line with the Differentiated Service Delivery model now fully implemented post lockdown.

The adoption of the DBS mode of sample collection was novel during the lockdown period. This helped to sustain the client level monitoring and adherence to ARVs.

Conclusion

The availability of ARV drugs in the community pharmacies and the strategy of home delivery of ARV prevented client’s drug stock out. The model adopted for easy access to drug refills is highly recommended and the strategy should be adopted and sustained.

At the ease of the lockdown, the viral load sample collection was reverted to the plasma collection as provided for in the country HIV and AIDS national guideline.

Contact Information

Name: Dr Monsurat Adeleke
City: Lagos
Organization: Lagos State AIDS Control Agency (LSACA)
Email: monsuratadeleke@outlook.com
Phone number: +2348033088168

Best Practice Information

Best Practice Title

Gradual Roll-Out of HIV Self-Testing Trainings for HIV Counsellor Testers

Best Practice Type

• Intervention
• Strategy / Guidelines

Best Practice Domain

• Accelerating uptake of proven interventions/policies/diagnostics/medicines

Best Practice Primary Audience

• Community 
• Government/Policy Maker
• Health Department or Ministry of Health

Best Practice Description

Introduction

Lagos State has a mixed HIV epidemic party driven by the key and general populations. The state has an estimated population of above 24 million (Lagos Bureau of Statistics), with the Adolescent and Young People (AYPs) accounting for 43% of the population. The adolescents (10-19 years) account for 8% of persons living with HIV according to findings by the Nigeria HIV and AIDS Indicator and Impact survey (NAIIS 2018).

The low access and uptake of HIV Testing Services (HTS) by adolescents and young people coupled with risky behaviours, such as multiple sexual partners, transactional sex, gender-based violence and HIV stigma and discrimination increases adolescent vulnerability to HIV infection. The HIV and AIDS social stigma has significantly mired the uptake and utilisation of HIV prevention services by AYPs.

Description

The aforementioned created the dire need to strengthen the existing youth friendly HIV and AIDS prevention interventions in the State. In view of the importance of the youth in the State development plan, the Lagos State AIDS Control Agency (LSACA), the organisation in charge of the city's multi-sectoral HIV/AIDS response, collaborated with the Ministry of Education and the Ministry of Youth and Social Development. This collaboration was to roll out the AYP HIV Prevention Campaign in the State run Secondary and Tertiary Education institutions and the youth centres.

The design and execution of the State level AYP HIV prevention campaign involved the use of a multi-layered approach, which increased the AYPs demand creation for HIV testing. The state reactivated the Family Life HIV/AIDs Education in the 354 State Junior public schools, in collaboration with the Ministry of Education.

Furthermore, LSACA trained 31 Youth Officers from the Ministry of Youth and Social Development on HIV counselling and testing, deployed HIV Self-Testing kits with HIV Information, Communication and Education materials (IEC) alongside condoms to the 31 youth centres in the State. The youth who need further information on HIV or tested positive are linked to the Information Center through a mobile phone toll free line 6222 for counselling and referral to care. This toll-free line was created by the National Coordinating Agency with the support of UNICEF.

To address the low access and uptake of HTS in the state by AYPs, the year 2020 World AIDS Day platform, was used to officially launch the deployment of HIV Self-Testing (HIVST) Kits in the State, using a political influencer: the wife of the State Governor. In a bid to increase the awareness, the Agency also partnered with Academia, the Nigeria Institute of Medical Research (NIMR) Yaba, Lagos, to create awareness of HIVST kits through a youth oral presentation competition. The top ten youth groups proceeded to design social marketing strategies and awareness creation for an increased demand and uptake of HIVST kits among the youth in Lagos. The winners of the competition were awarded with 1,000 units of HIVST kits, for a revolving social marketing strategy designed by the group which is currently sustained and has increased stock/demand by 20%, one year after the competition. The platform of Anti-AIDS clubs in Secondary and Tertiary institutions was also used for awareness and demand creation for HIV self-test kits with the support of LSACA.

Data Collection

The State, implementing partners and CBOs adopted the National HTS data collection tools to document HIVST uptake in the period under review. The validated HIVST data from the State was reported to the National Agency for the Control of AIDS (NACA) and the Federal Ministry of Health (FMOH) as HIV testing in-disaggregated data (RTS and HIVST).

The baseline data for HIV Self Testing in the State was zero prior to the December 2020 launch of Self-testing, however, since the launch, the State has recorded the use of over 44,028 HIV Oral Self-test kits, which accounts for 17.7% of the of Non-health sector HIV testing services as of December 31, 2021.

The city had a target of achieving 50% of the rapid testing conducted among the youths within the year under review (December 2020- December 2021). By the end of the year 2021, the total HIV rapid testing conducted among the Youths aged 15 to 35 was 34,196 and the HIV self-testing achieved was 44,028 with the support of various stakeholders (the State, CBOs, and Implementing Partners).

Results, Outputs, and Outcomes

1. These strategies account for a 129% increase in acceptance and demand generation of HIV self-testing. The increase in self testing uptake since the launch shows significant return on investment in terms of increased demand for HIVST services in the state.

2. The mode of delivery of HIVST that encourages confidentiality and reduced stigma has resulted in an increased demand for the service among the youth.

3. There is an ongoing pilot project designed to support the supply of HIVST kits to Private Patent Medicine Vendors (PPMVs) free of charge, to be sold to the clients for between $3-$4 per unit, and the proceeds used in a revolving scheme. The country is currently developing data collection tools to capture the HIVST data of these clients.

Lessons Learned

1. Increased availability and access to the HIVST kits, through Government, implementing partners and over the counter in for profit pharmacy establishments will sustain the momentum for the increased demand currently achieved.
2. Increased involvement of the youths in HIV program design, planning and implementation, improves program outcome and effectiveness.
3. The use of the political platform increased the publicity and awareness creation on the product, it also increased Government commitment and domestic resource mobilisation for the state’s HIV/AIDS response.

Conclusion

1. The introduction of HIV self-testing kits in the state HIV/AIDS response has increased the youth demand and uptake of HIV testing services.
2. Youth involvement in the designing, planning and implementation of youth related intervention is vital towards successful program outcome and sustainability.

Contact Information

Name: Dr Monsurat Adeleke
City: Lagos
Organization: Lagos State AIDS Control Agency (LSACA)
Email: monsuratadeleke@outlook.com
Phone number: + 2348033088168

Best Practice Information

Best Practice Title

Home Delivery of ART And HIV Self-Testing Kit to PLHIV And Key Populations

Best Practice Type

• Intervention

Best Practice Domain

• Promoting early initiation of and adherence to HIV treatment
• Meeting the needs of key populations
• Enhancing retention and long-term engagement in HIV care with viral load suppression
• Eliminating stigma/discrimination, notably within health settings
• Finding and testing HIV unawares, especially young men and women
• Accelerating uptake of proven interventions/policies/diagnostics/medicines

Best Practice Primary Audience

• Donor
• Community
• Government/Policy Maker
• Health Department or Ministry of Health
• Implementing Partner
• Clinician

Best Practice Description

Introduction

Rwanda adopted strong measures to prevent the spread of COVID-19 including long term strict lockdown in all districts of Rwanda. The movement were strictly limited to everyone and people were requested to stay at home. People living with HIV on ART, new HIV infected who want to initiate ART or those who wanted to test for HIV were at high risk of not accessing services at usual. Though, the government offered a channel to request officially the pass permission to people with a clear reason of getting out. However, for people living with HIV or who want to access HIV related services with self-stigma were not ready to use official channel of requesting permission. Therefore, Network of people living with HIV, Ministry of Health/Rwanda Biomedical center/HIV program had to find out a home delivery approach of ART and Some HIV services to people ling with HIV and everyone who needed the services.
The biggest challenge was how to access ART during COVID-19 lockdown for PLHIV, Initiate ART for the new infected and accessing HIV testing services for those at high risk. The major affected were PLHIV and key populations. Interruption of ART among PLHIV leads to resistance on treatment, that can affect poorly the outcome of patients. The objective of the intervention was the following:
1. Ensure Continuation of accessing ART to PLHIV during lockdown
2. Ensure continuation of access to HIV testing to key populations

Description

The intervention focused on ART drugs and HIV self-testing home delivery to PLHIV and key populations during lockdown. A toll-free number (1245) was availed to everyone who have difficulties to access ART or HIV testing services. The home delivery services are still available even after lockdown. It was found that this approach reduced remarkably the lost to follow up and increased the HIV testing uptake. The service is being offered in Kigali and out of Kigali through coordination of Network of people living with HIV, Rwanda Biomedical center/HIV program and HIV partners in Rwanda. The drugs are being picked up to nearest health center and delivered by peer educators in that area.

Data Collection

The current indicators are being collected:
1. Number of PLHIV used toll free to access services
2. Number of PLHIV received ART at home
3. % of lost to follow up
4. Number of key populations used toll free to access services
5. Number of Key populations received self-testing kit at home

Results, Outputs, and Outcomes

So far there is no formal evaluation of the practice carried out. However, end March 2021 report showed 1790 PLHIV received their ART at home through this intervention.

Lessons Learned

Enablers:
1. The strong collaboration between Network of people living with HIV and Rwanda Biomedical Center /HIV Program enabled health centers to accept to give peer educators ART so that can be delivered at home.
2. The collaboration of Network of people living with HIV with partners (UNAIDS, GIZ, IAPAC) and Ministry of health enabled the set up and operations of toll free

Challenges:

1. Toll free requires permanent staff working 24/7 to ensure quality services but support availed was only 7/7. The recommendation was to go for 24/7 to not miss anyone behind
2. The toll free was only for home delivery, unfortunately more other complains among PLHIV were reported such domestic violence among discordant couples during lockdown etc…, the staff were overwhelmed with complains.

Conclusion

The intervention protected PLHIV for being exposed to COVID-19 during the movement of going in and out from their homes to Health centers. In addition of minimizing interruption to continuation of access to ART and early identification of HIV new infection.

Sustainability/Continuity during COVID-19

The Home delivery of ART drugs and self-testing kits was found to be of high importance to reduce lost to follow up and up taking HIV testing. This approach respond to UNAIDS global goals 1st 90 to know your HIV status, 2nd and 3rd 90 for retention and VL suppression. The approach is still valid even after lockdown since Rwanda adopted home based care approach for asymptomatic COVID-19 Confirmed cases. Therefore, PLHIV if he/she is confirmed COVID-19 positive then ART can still be delivered at home.

Contact Information

Name: Muhammed Semakula
City: Kigali
Organization: IAPAC
Email: msemakula@iapac.org
Phone number: +250788483570

Best Practice Information

Best Practice Title

Tanya Marlo, Artificial Intelligence Based Chatbot to Reach Out to Young Key Populations In Jakarta

Best Practice Type

• Intervention

Best Practice Domain

• Meeting the needs of key populations
• Eliminating stigma/discrimination, notably within health settings
• Addressing disparities in access to/utilization of HIV services
• Facilitating an effective interface between health services/community services
• Finding and testing HIV unawares, especially young men and women

Best Practice Primary Audience

• Community

Best Practice Description

Introduction

Young people in Jakarta (aged 15-39 years) often find it difficult to find information about sexual and reproductive health rights, as well as HIV services. There is also a need to expand outreach strategies to different target audiences through innovative means.

Description

In the spirit of reaching out to the younger generation, UNAIDS Indonesia and Nimbly Technologies are developing "Tanya Marlo", a chat robot (chatbot) based on Artificial Intelligence, which is designed for conversations about HIV and AIDS. Marlo is connected to the LINE chat messaging app.

Tanya Marlo or Ask Marlo has several features:

• Articles, infographics, myths-facts, videos and other informative content regarding topics around HIV/AIDS
• Questions and answers regarding HIV/AIDS in an interactive quiz format
• Access to a trusted counselor that can help answer questions regarding HIV/AIDS
• List of clinics that provide HIV testing, as well as relevant information such as location, pricing and opening hours
• Online booking for HIV test. Partnering with FHI 360 / Linkages', the chat bot allows users to make HIV test appointments without exiting the LINE app. Users can make appointments at 8 clinics in Jakarta, as well as see clinic references throughout Indonesia. Especially for clinic bookings in Jakarta, proof of reservation will be sent via email

Data Collection

Social Media outreach (Facebook, Twitter, Instagram and Line), Website traffic, and online ads

Results, Outputs, and Outcomes

The impact of the Tanya Marlo platform is continuously measured with a monthly monitoring report, which recaps the reach of the campaigns on all the social media platforms. The monthly monitoring report is able to provide insights into what topics and issues are most frequently sought after by the public. As of February 2022, Marlo campaign reaches more than 17,800 users in all platforms. In addition to this, the Tanya Marlo platform also refers users to counselling services that link them to access services. The counselling, provided by the network of PLHIV, is also monitored regularly and saw a decline due to Covid-19 pandemic decreasing people’s willingness to visit health facilities.

Lessons Learned

• Increase knowledge and understanding of HIV/AIDS among young people, particularly MSM
• Making sure the user interface is interactive and friendly, including the characters

Conclusion

In the setting where HIV/AIDS is stigmatized, Tanya Marlo provides easy access for young people to receive credible information and services. This can be applied in other settings with similar barriers on access to information.

Sustainability/Continuity during COVID-19

Transition of Tanya Marlo management from UNAIDS to Yayasan Kasih Suwitno (YKS) which also manages the campaign and platform @sayaberani. Also need to continue to improve Tanya Marlo's performance by strengthening social media and websites. Tanya Marlo is a collaborative effort, involving many stakeholders including community organisations as the implementing partner who create content and provide counselling on the platform, as well as development partners who support the platform’s establishment and maintenance.

Contact Information

Name: Tono Permana
City: Jakarta
Organization: Yayasan Kasih Suwito
Email: tonobytono@yahoo.com

Best Practice Information

Best Practice Title

Multiple Use of ART Expert Clients

Best Practice Type

• Intervention

Best Practice Domain

• Promoting early initiation of and adherence to HIV treatment
• Enhancing retention and long-term engagement in HIV care with viral load suppression

Best Practice Primary Audience

• Community
• Health Department or Ministry of Health
• Implementing Partner

Best Practice Description

Introduction

The major problem being addressed by the Best Practice is poor HIV treatment outcomes. The intervention is addressing issues around poor adherence among people taking HIV medication, high default rates, delayed ART initiation, poor communication between recipients of care and service provides, poor family and community support systems. The Expert client intervention targets the general population of people living with HIV on ART, with a special emphasis on pregnant women, the AGYW, and men as there is sufficient evidence that those subgroups need more attention.
After someone has been initiated on ART, the expectation is his/her viral load will be suppressed leading to an increase in the quality of life and less infectious. If this fails, people will be sick at home due to opportunistic infections leading to being less productive. Currently, the death rate due to HIV is not high but chronic illness has resulted in children almost running the family. As a city, we still facing a high incidence of HIV. Data from the recency study shows that we still have a lot of new infections.

The intervention aims at improving the adherence and retention in care for people on HIV treatment. The expert clients also make sure that clients in care fully utilize available HIV services with an aim of having their quality of life improved. The fact that the intervention is using trained and experienced clients on ART, it makes it much easier for them to link and bring back those people who have been lost in care.

The intervention is working towards assisting the city to achieve its 95, 95, 95 UNAIDS treatment targets. This is being done through the following
- To facilitate HIV index testing for families and sexual partners of newly identified PLHIV
- To facilitate early linkage of clients newly diagnosed with HIV
- To bring back to care HIV clients who missed their appointments or were lost in care

The use of expert clients is key throughout the HIV treatment cascade. The same concept has yield positive results in identifying new HIV positive clients especially in the key population program. The concept is more like the global Meaningful Involvement of People living with HIV (MIPA). For the country to identify the few remaining people living with HIV not yet diagnosed, their involvement is key for re-direction in targeting. The same also applies to keeping people in care. All these efforts will have an impact in viral load suppression, the ultimate treatment goal.

Description

Activities being implemented are:
HIV index testing
– Increase awareness through one on one communication on the need and importance of index testing
– Follow up on index clients who have not yet turned up for testing
Linkages
- Identifying newly diagnosed clients that have been linked for various services, especially ART
- Provide peer counseling and psychological support
- Escorting clients for different services
Bringing clients back to Care
- Identification of clients who have missed their appointments
- Making phone calls to clients who have missed their appointment for 7days
- Making phone calls and home visits for ART clients who have missed their appointments by 14days
- Conducting home visits for defaulters
- For newly initiated clients the following, first follow up is done at 6months, expert clients will make sure VL is done, and also explain the results
Other activities include;
- Peer mentor support
- Health Education
- Adherence support
- Provider initiated testing and counseling (PITC)
This approach brings together many partners in HIV testing and treatment. This includes the Ministry of Health through the public health facilities and the ministry headquarters (Department of HIV and AIDS). The ministry of health has an active Differentiated Service Delivery Model section with a desk officer to support this service delivery model. The project is being implemented by Mothers2Mothers, being a sub-grantee of the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) with funding from USAID. The program is integrated within the Ministry of Health ART program in the public health facilities. The other partners involved include the Malawi AIDS Counseling and Resource Organization (MACRO) and Community Based Organizations within the locations. The general community is involved as the expert clients are part of the community based organizations (CBOs). CBOs are not only for people living with HIV, they have a lot of sub-groups and support groups for PLHIV is just one of them. The approach is ethical and those enrolled or targeted are still treated with dignity and their rights are respected. Most of these expert clients are also representatives from the local community based organizations.

The innovation is supported by both local and national authorities. At both levels, partners also provide technical support to the structures and also direct to the program. The expert clients are attached to partners and the ART/PMTCT focal person at the health facility. The focal person is also attached to the City/District ART/PMTCT coordinator for support. This initiative is not meant to share technical knowledge or experience but it’s a platform for those living with HIV to share their life experiences in care with an aim to encourage each other to stay on treatment.

Data Collection

Below are some of the indicators for tracing
Number of missed appointments after 14 days
Number missed appointments after 14 days Not traced up
Number missed appointments not traced after 14 days - Not traced due to absence of physical address or phone number
Total traced
Number of missed appointments after 14 days traced up physically only
Number of missed appointments after 14 days traced up by phone only
Number of missed appointments traced up physically and by phone
TOTAL TRACED
Number of missed appointment after 14 days brought back to care
Number of missed appointment after 14 days Not traced but Self brought back to care
Number of missed appointment after 14 days traced up but Self Transferred Out
Number of missed appointments after 14 days traced up but died
Number of missed appointments after 14 days traced up but stopped ART
Number missed appointments after 14 days traced up but Promised to come
Number missed appointments after 14 days found on ART due to poor adherence
Number missed appointments after 14 days found on ART due emergency supply from another facility
Number of missed appointments after 14 days traced up but Lost To Follow UP (LTF)
Total outcome

Linkage indicators include
- Number of clients linked for ART
- Number of clients linked for other HIV related services

Results, Outputs, and Outcomes

No external evaluation has been done yet but the program data is showing positive results as the number of missed appointments is reducing. In 2021 quarter 3, a total of 873 clients on ART missed their appointments by more than 14 days. The expert clients managed to trace (91%) of them either by phone (18%) or physically (75%). Through counseling, they managed to bring back to care 59.8% instantly and 26.7% promised to visit their nearest health facility later for their refill. It was also discovered that 0.5% had received emergency medication from other health facilities and 7.3% were lost to follow-up. Through the expert client program, 99.6% of those who missed their appointment by more than 14 days had clear outcomes after tracing. The project recruited 110 expert clients spread across 24 health facilities. Each health facility is allocated about US$20-30 per month for phone calls used for client tracing. Facility allocation of expert clients and airtime is based on ART patient volume. Data shows that about 18% of the clients are traced through phone calls and the remaining proportion (72%) is traced physically

Despite that this initiative has not been evaluated externally, the approach has a component of efficiency as it is targeted based on the available program data. The expert clients only target the newly initiated clients, those who missed their appointments and those who have been lost in care. For the newly initiated clients, group counseling is done and suspected clients who are most likely to miss appointments are identified for individual counseling. Examples of such clients include adolescents, men and pregnant women. Not everyone on HIV care needs direct support.

Lessons Learned

The peer support concept seems to be bringing positive results as clients also share experiences with other peers. Now there is also open communication as the expert clients have more time to talk to ART clients. Critical issues are being resolved through the specialized clinic staff. The expert clients are role models and are identified from the same community where the clients reside. This has helped to easily follow up and to identify other reasons why clients were lost in care.

The greatest challenge was enrolling expert clients who at least had completed secondary school education. These could not be found, the program had to recruit those whose educational level was below secondary education. The challenge was these people could not easily learn some of the program aspects such as report writing, and lessons in English. It slightly compromised the quality of services being provided especially during the early phase of the program. The other challenge was the ratio between expert clients and ART clients. Some high-volume sites with about 5000 clients on ART had only 10 expert clients. Sometimes expert clients could be overwhelmed with work.

Conclusion

Sustainability/Continuity during COVID-19

In the presence of COVID-19, the program can still take place, for follow-ups, phone calls and texts can be used to remind those people who have missed their appointments. Home visits can also be done for defaulters as the expert clients live in the same community as their ART clients. Each expert client is attached to clients within his/her residential area.

The concept can be replicated as expert clients can be recruited from already existing structures and organizations such as support groups for people living with HIV, members for active PLHIV forms and those individuals who have already disclosed their status to the community. Volunteers can be drawn from the health facility ART cohort as always is the case. Because the identified individuals are already in care, minimal training is required for them to start the peer to peers experience sharing and the rest is done as mentor as the expert clients practice.

Contact Information

Name: Maiden Mahowe
City: Blantyre
Organization: Mothers2mothers
Email: maiden.mahowe@m2m.org

Best Practice Information

Best Practice Title

Integrating Quality Improvement in HIV Programs (Pre-Exposure Prophylaxis)

Best Practice Type

• Intervention

Best Practice Domain

• Meeting the needs of key populations
• Accelerating uptake of proven interventions/policies/diagnostics/medicines

Best Practice Primary Audience

• Researcher/Academia
• Health Department or Ministry of Health
• Implementing Partner
• Clinician

Best Practice Description

Introduction

HIV incidence is high in Blantyre, especially among the key population (MSM, FSW, and partners of FSW) and AGYW. New interventions are being implemented without effectively integrating the learning component for quality improvement. The intervention is addressing issues around suboptimal coordination and low uptake of PrEP in Blantyre city. PrEP is effective scientifically but there is a need to address quality issues for proper implementation and obtaining maximum gains from the intervention. Having a higher incidence among the key population and the city thinks if PrEP is effectively implemented then Blantyre city can be able to reduce HIV incidence. The higher the incidence of HIV among the vulnerable populations the greater the risk of city residents getting HIV. That also translates into an increase in the HIV prevalence rate. This means that the HIV burden in the city will not reduce.

The intervention has the following objectives;
• Develop data-driven, community-informed, responsive, and adaptive prevention programs that are attractive to at-risk populations
• Deliver quality HIV prevention services through coordinated public and private delivery channels at the community and facility level to populations most at risk of HIV acquisition
• Measure program performance, quality, and effectiveness of prevention programs in reducing incidence to adapt and expand user-provider interfaces as needed.

Description

Through the PrEP QI Collaborative, we strengthen QI structures at both district and facility levels. This is done to enable the city/district and facilities to be capable of using QI methods to improve the quality and uptake of HIV prevention services including PrEP and expand the targeting of these services to the at-risk population The main activities within the program are;

• QI capacity building for facility-based QI team, district QI mentors team, and leadership through monthly QI mentorship
• Testing of change ideas along the PrEP cascade to improve access and quality of services
• Providing a platform for sharing best interventions through collaborative learning sessions. Meetings are conducted quarterly with representatives from all health facilities providing PrEP and PrEP partners.
• Data deep dives on PrEP data and other HIV-related data to inform facility and district actions. Each facility makes a poster presentation highlighting its achievements, challenges, and plans for the following quarter.
• Sharing of demand creation for PrEP through health education and distribution of IEC materials The activities are implemented in 21 health facilities in Blantyre which make up the PrEP UP! Collaborative.

The QIC was launched in September 2021 with the first learning session however pre-work activities started in August 2020. PrEP collaborators include DHO, DREAMS project, EGPAF, MACRO, IAPAC, Lighthouse, PAKACHERE, Queen Elizabeth Central Hospital, University of Malawi, and Cooper Smith among others Below are some of the indicators monitored for the program • Process data to inform the quality of the PrEP delivery process and QI program processes o No. of people screened for PrEP eligibility o No. of people eligible for PrEP o No. of people enrolled for PrEP o No. of people retained on PrEP at 1 and 3 months • Outcome data focusing on outcome indicators for the PrEP program • QIC has 9 indicators ( both process and Outcome) • Data is collected every month by facility data officers and sent to HIMS under the ministry of health

Data Collection

Data is collected every month by facility data officers and sent to HIMS.

Results, Outputs, and Outcomes

• QI structure which includes district QI leadership, a team of district QI mentors, and facility-based QI teams are up and functional.
• QI leadership which includes district QI focal person and HIV prevention coordinators strengthened and led QI collaboration in Blantyre
• 20 QI mentors trained and mentored now leading QI coaching and mentoring in Blantyre
•  88 facility based QI team members trained in QI methods
•  22 QI teams strengthened through QI coaching and mentoring now leading to the testing of changes ideas to accelerate the uptake of PrEP in Blantyre
• 44 data officers oriented on data management for improvement.
• As of December 2021, 21 facilities had integrated PrEP into their services from 7 facilities at baseline (March 2021)

The table below shows program outputs on a quarterly basis for 2021.

The table above shows that after the project was introduced, only 19 people were initiated on PrEP out of the 63 screened during the first quarter. In the same quarter, about 45.8% of those screened refused to be initiated on PrEP. Due to collaborative learning, the project outputs changed from one quarter to the other, in quarter 2, the refusal rate significantly reduced and the number of people initiated on PrEP increased by 974%. In quarter 4 we had the highest number of PrEP initiations (1080)  double the previous quarter. Currently, the project is working on increasing the retention rates. The project started with a 1 monthly retention rate of 43% and by end of December 2021 retention rate was now at 53%. For the 3 months retention, at the beginning of the program, this was at 38% and by end of December 2021, it had improved to 44%. The project is still working towards improving the retention rate.

So far the project has been successful in increasing the number of people assessed for PrEP, increasing the number of people initiated in PrEP, and increasing PrEP acceptance rate.

Lessons Learned

Quality improvement methods, including process mapping, root cause analysis, and testing of changes, inform how to adapt systems to effectively deliver PrEP and other HIV prevention services routinely in health care facilities
• Integrating PrEP screening and demand creation in multiple service areas has shown promise in increasing PrEP uptake
• PrEP taskforces and designated champions facilitate agency-wide delivery and improvement of PrEP services
• Collaboration and coordination with key IPs are key to the success of PrEP implementation
• QI Mentor’s program approach is key to building QI capacity at district- and site-level
• Learning Sessions provide an important platform and forum for peer sharing and exchange of PrEP implementation successes and challenges
• The leadership of the DHO in another district is essential for replication. QI capability, including QI coaching, would need to be built if not present.

Conclusion

Sustainability/Continuity during COVID-19

The leadership and mentoring team built at the district level through a QI focal person and a team of QI mentors respectively will provide oversight for the collaborative and continued QI coaching and mentoring to facility QI teams beyond the funding time frame. The QI teams at the facility and district level are well trained to implement the intervention. QI supervision visits can be integrated into other routine visits done by the district to facilities. Some of the activities can also be integrated into the District/city implementation plan for funding by the government. The Ministry of Health has a QI department with specialists who can ably implement the intervention.

Supplemental Tools and Resources

Contact Information

Name:Moses Enock
City: Blantyre
Organization: Maikhanda Trust
Email: m-enock@maikhanda.org
Phone number: +265884012196

Best Practice Information

Best Practice Title

The Rollout of A Community-Led Monitoring (CLM) Advocacy Model

Best Practice Type

• Policy
• Strategy / Guidelines

Best Practice Domain

• Meeting the needs of key populations
• Enhancing retention and long-term engagement in HIV care with viral load suppression
• Eliminating stigma/discrimination, notably within health settings
• Addressing disparities in access to/utilization of HIV services

Best Practice Primary Audience

• Community 
• Government/Policy Maker
• Health Department or Ministry of Health
• Researcher/Academia
• Donor
• Implementing Partner
• Clinician

Best Practice Description

Introduction

In Cameroon, the HIV epidemic remains a public health problem. Although the prevalence in the general population dropped from 4.3% to 2.7% between 2011 to 2018 (EDS, 2018), the prevalence in major cities like Yaounde is higher at 4.4 % CAMPHIA 2018) with an estimated number of 85736 People Living with HIV (2021 Spectrum). The existence of Users Fees has been reported as a major challenge to accessing quality services by the communities of People Living with HIV(PLHIV), consequently contributing to the delay in the attainment of the 95-95-95 2030 targets.
In response to this, the government of Cameroon through the ministerial decision N°0498/D/MINSANTE/SG/CNLS/GTC/SP of 04 April 2019 enacted a policy for the elimination of ‘USERS FEE’’. The policy aims to remove all fees charged at health facilities for the provision of diagnostic, care and treatment services to PLHIV. To ensure that PLHIV continue to receive quality services with the rollout of this policy, there is a need for continuous monitoring at the facilities with routine feedback from the receivers of care. It is in this regard that the National Network of PLHIV in Cameroon (RECAP+), with support from USAID, UNAIDS and the government of Cameroon is rolling a nation-wide project on Community Led Monitoring and Advocacy (CLM) for the provision of quality services to PLHIV which free of charge. This is done through improved community participatory monitoring systems and has the following objectives;
1. Strengthen the existing system to monitor the elimination of HIV-related user fees at health facilities and share findings with all stakeholders,
2. Foster health facility compliance in quality and quantity with the new government policy focused on eliminating user fees at HIV service delivery points,
3. Empower PLHIV and communities to leverage evidence gathered to demand improved access to and quality of services.

Description

Data Collection

Data is collected from two main sources. PLHIV and health personnel through self-administered questionnaires. An average of 243 health workers and 584 beneficiaries of HIV services are expected to complete the questionnaires from 81 health facilities and 6 health districts in the city of Yaounde. This collection is carried out by site Monitors who are supervised by Community Based Organisations (CBOs). The data collected is routine programmatic data.

1. Percentage of HIV health care providers who are aware of the existence of the national policy on free user fees on HIV/AIDS services during the reporting period per type of health facility: This is the proportion of healthcare providers who are aware of the existence of the free user fee policy. Health care providers should be aware of all the components of the policy.
2. Percentage of health facilities who adhere to the national policy on free user fees on HIV/AIDS services during the reporting period per type of health facility: This is the total number of health facilities that offer for free the HIV/AIDS services contained in this national policy. Health personnel in these health facilities should offer for free ALL these HIV/AIDS services in the policy.
3. Number of people sensitized during advocacy meetings to raise awareness on free user fees policy by category of health personnel (frontline providers, health administrators, and their health staff), type of health facility, and region: This is the total number of people sensitized during advocacy meetings to raise awareness on free user fees policy by category of health personnel
4. Percentage of PLHIV who are aware of the free user fees policy on HIV/AIDS services within the period per means of sensitization: This is the proportion of PLHIV interviewed during a period who know the existence of this free user fees policy and at least a means of sensitization. When PLHIV is not aware of some of the HIV/AIDS services that are supposed to be offered for free, the PLHIV is considered to be partially aware. When the PLHIV is not aware of any of the free HIV/AIDS services, he is considered to be unaware. A PLHIV is considered to be fully aware If s/he knows all the HIV/AIDS services that are supposed to be offered for free
5. Percentage of PLHIV who have benefited from the free HIV/AIDS services during the reporting period per type of HIV/AIDS services: This is the percentage of PLHIV interviewed during a period who have benefited from a free user fee policy. Here the percentage for each of the HIV/AIDS services is computed.
6. Percentage of PLHIV who have paid for HIV/AIDS services indicated in the user fee policy during the reporting period per type of HIV/AIDS services: This is the percentage of PLHIV interviewed during a period who paid for these HIV/AIDS services during the reporting period. Here the percentage for each of the HIV/AIDS services is computed.
7. Percentage of PLHIV who have not benefited from free HIV/AIDS services during the reporting period due to stock out of inputs: This is the percentage of PLHIV interviewed during a period who did not benefit from the free user fees policy because of a stock out of inputs. Here the percentage for each of the results for each of the HIV services is computed.

Results, Outputs, and Outcomes

The preliminary results from the rollout of the intervention are seen on the table below;

The key finding reveal that there is an increase awareness and adherence to the national policy on the elimination of users fee at the level of the health facility. Over the last three months the proportion of PLHIV who have benefited from HIV free services has increased from 88% in January to 90% in March 2022. In addition to this there has been a 2% decrease in the number of people who have paid for HIV services.

Lessons Learned

1. Highly qualified staff in key positions are imperative in the successful implementation of a CLM system; when key personnel are highly experienced, there can easily identify risks and problems and put in place mitigation measures ahead of time.
2. When there is acceptance of the CLM system by the government, it leads to close collaboration between the government and the civil society organizations, easing the acceptance of the system at all levels as well as implementation at all levels.
3. When CBO support is poor coupled with poor staff renumeration, it leads to high turnover; high turnover will greatly influence progress in attaining results thus, negatively affects successful project implementation due to continuous recruitment and training of new comers

Conclusion

Contact Information

Name: Mr. Landom Henry Shey
City: Yaoundé
Organization: RECAP+
Email: landomshey@yahoo.com

Best Practice Information

Best Practice Title

G-POWER: Girls—Protected, Optimistic, Wise, Enlightened, Responsible, and Resilient. A comprehensive program to support pregnant and breastfeeding adolescent girls and young women and their infants to achieve and sustain health and well-being

Best Practice Type

• Intervention

Best Practice Domain

• Promoting early initiation of and adherence to HIV treatment
• Enhancing retention and long-term engagement in HIV care with viral load suppression
• Addressing disparities in access to/utilization of HIV services
• Finding and testing HIV unawares, especially young men and women
• Linkage to HIV care and support services
• Improving health-related quality of life and quality of care
• Accelerating uptake of proven interventions/policies/diagnostics/medicines

Best Practice Primary Audience

• Donor
• Government/Policy Maker
• Health Department or Ministry of Health
• Implementing Partner

Best Practice Description

Introduction

Adolescent girls and young women (AGYW) aged 10–24 are a unique population facing distinct social, economic, health, and developmental risks. Globally, AGYW represent a population disproportionately affected by HIV, gender-based violence (GBV), and pregnancy—also referred to as the triple threat. A number of factors affect their autonomy and agency in preventing transmission of HIV, GBV, and pregnancy: a lack of available, comprehensive sexual and reproductive health education, relationships with older men or with multiple partners, transactional relationships, low condom use, coercion, early sexual debut, and other pressures and stigmas.

Description

In recognition of gaps within the cascade of care for pregnant and breastfeeding (PBF) adolescent girls and young women (AGYW) and their infants, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) Kenya, with support from The ELMA Philanthropies, designed and implements a tailored, multipronged, and sectoral package of care aimed at providing quality, comprehensive, peer-centric care for improved retention and clinical outcomes among PBF AGYW and their infants. This package, known as G-POWER, refers to girls who will be protected, optimistic, wise, empowered, and resilient through the support of the program. Initiated in 2020, G-POWER is being implemented in 36 facilities in Homa Bay County, Kenya, with 40 trained and capacitated AGYW peer mentors spearheading the approach. The G-POWER program is a multidimensional approach that aims to address specific gaps in the care continuum in responding to the triple threat, and to support PBF AGYW and their infants in achieving optimized outcomes and health through a peer-centric case management and multidisciplinary team approach. Although the program is focused on provision of care and support through layered means to all PBF AGYW and their infants, activities focused on the needs of HIV-positive and HIV-negative AGYW are prioritized to ensure continuation of treatment and prevention as well as optimized GBV screening, identification, and linkage as needed.

Data Collection

Key indicators measured include: Pregnancy screening and linkage to ANC or PMTCT among PBF AGYW, Jan–Jul 2022; HIV testing, retesting, and positivity among PBF AGYW across the ANC–PNC cascade, Jan–Jul 2022; HIV positivity among PBF AGYW re-testing along the ANC–PNC cascade Jan–Jul 2022; AGYW linked and provided with FP methods from Jan–Jul 2022; HEI attendance among mother-baby pairs in G-POWER; Deliveries and Skilled Deliveries among AGYW; and AGYW linked and provided with FP methods from Jan–Jul 2022.

Results, Outputs, and Outcomes

As a result of the G-POWER program, several outcomes across the pregnancy and postnatal cascade for the PBF AGYW and her infant have improved:

1. 1. Earlier identification of pregnant AGYW through standardized use of pregnancy screenings and prompt linkage to ANC, PNC, or PMTCT
   2. Implementation of HIV retesting across the ANC and PNC cascade with fidelity, following up on missed opportunities, and rapid identification of seroconversion cases for prompt ART initiation
   3. Reduced rates of seroconversion along the pregnancy and postnatal cascade observed among PBF AGYW in the G-POWER program
   4. Improved skilled delivery
   5. Comprehensive care and support for HIV-exposed infants
   6. Integration of social support and social protection
   7. Facilitating school re-entry for PBF AGYW
   8. Increased identification of GBV cases among AGYW and linkage to care and support

Lessons Learned

The significance of the G-POWER program should not be understated. The elements that allow the G-POWER package to optimize outcomes, reach and impact across all service points include specifically integrated activities in addition to the standard of care (SOC) executed by capacitated teams. These elements include:

1. 1. Pregnancy assessment—screening, testing, risk—conducted for all AGYW presenting to the facility
   2. Early identification and strategic capture of PBF AGYW and linkage to care—both HIV+ and HIV-
   3. AGYW peer mentors providing peer support to PBF AGYW including counseling, navigation and linkage to services, individualized case plans to provide care based on specific needs
   4. Retesting PBF AGYW with fidelity—line listing those eligible in combination with appointment reminders conducted by peer mentors
   5. Immediate linkage to ART for any PBF AGYW testing positive during retesting throughout the ANC–PNC cascade
   6. An audit conducted in the case of a seroconversion to identify the reason and respond accordingly
   7. Integration of GBV, pregnancy, and HIV screening and testing for all presenting AGYW
   8. Adolescent and youth-friendly health services with trained and capacitated HCWs and peer mentors
   9. Screening and referral for postpartum depression for all PBF AGYW

Conclusion

The G-POWER project demonstrates significant promise in providing solid evidence for establishing a comprehensive, peer-centered case management approach to support HIV-positive and HIV-negative PBF AGYW and their infants in achieving and maintaining health and well-being throughout and after pregnancy.

Supplemental Tools and Resources

• G-Power

Contact Information

Name: Job Akuno; Paul Nawiri; Susan Dorcus Anyango Omonodi; Truphosa Ocholla; Cosima Lenz; Mary Spencer
City: Homa Bay, kenya
Organization: The Elizabeth Glaser Pediatric AIDS Foundation
Email: info@pedaids.org
Phone number: (202) 296-9165

Best Practice Information

Best Practice Title

Experiences of ANC Women with Distributing HIV Self Testing Kits to Male Partners in Eswatini

Best Practice Type

• Intervention

Best Practice Domain

• Finding and testing HIV unawares, especially young men and women

Best Practice Primary Audience

• Government/Policy Maker
• Health Department or Ministry of Health

Best Practice Description

Introduction

Late diagnosis of HIV remains a major public health concern, and many who are at risk for acquiring HIV do not seek HIV testing services (HTS). It is estimated that globally, in 2019, 19% of HIV-infected individuals remained unaware of their HIV status. Men are consistently less likely to ever test for HIV compared to women. In 2019, about 16% of men living with HIV (aged 15 years and above) in Eastern and Southern Africa did not know their HIV status compared to 9% of women living with HIV of the same age. In Eswatini, a household based HIV incidence measurement survey found that lifetime HIV testing and testing in the prior 12 months were higher among females (91.4% and 55.3%, respectively) than among males (81.9% and 47.2%, respectively). Distribution of HIV self-testing (HIVST) kits to ANC women to share with their male partners is a promising strategy for reaching men for HIV testing. The purpose of this study was to explore the experiences of ANC women, their providers, and men accessing services at selected facilities to inform the implementation of secondary distribution of HIVST kits as the program is scaled up in Eswatini.

Description

This was a qualitative, exploratory study using semi-structured in-depth interviews with conveniently selected ANC women, men and healthcare providers in six public health facilities from both urban and rural areas in Hhohho and Shiselweni regions in Eswatini. All 6 study sites were piloting secondary distribution of HIVST kits. Data was collected between October and December 2019. Interviews were audio recorded, and transcribed and translated verbatim. Transcripts were analyzed using both inductive and deductive content analysis approaches.

Data Collection

We collected data on the characteristics of ANC women and men; characteristics of health care providers; willingness to receive HIVST kits by ANC women and men; hypothetical and actual strategies to introduce HIVST kits to male partners; male partner reactions upon receiving HIVST kits from ANC women; challenges with the secondary distribution of HIVST kits to male partners; and participant recommendations for scaling up.

Results, Outputs, and Outcomes

In-depth interviews were conducted with 51 ANC women (25 received HIVST kits for the first time, and 26 received kits during a previous ANC visit), 19 men, and 24 health care providers. The median age of the ANC women was 24 years; most had secondary education or higher. All the 26 ANC women who had received an HIVST kit during a previous clinic visit reported sharing the HIVST kits with male partners; 21 reported their partner used the kit. Men’s median age was 34 years and most had high school or tertiary education. Nine men had ever used an HIVST kit, three of whom used the kit with their partner, and seven had disclosed test results to their partner. Most of the health care providers were female 83.3% (20), had attained tertiary education 83.3% (20), and were midwives 37.5% (9) or HTS counselors 29.2% (7).

Most Participants (ANC women, men, and health care providers) noted that it is acceptable for women to deliver HIVST kits to male partners. Many ANC women reported that they liked the idea of distributing HIVST kits to their male partners and accepted the HIVST kits to share with the male partners. The ANC women said that distributing the HIVST kits to male partners provides them with the means to introduce HIV testing to their male partners and allows them to learn their male partners’ HIV status in cases where they did not know it. Many ANC women reported that their male partners accepted the HIVST kit and even used the kit in their presence. Only a few women said their male partners refused the HIVST kit, citing as reasons that the male partners did not want to be forced or were not sick or already knew their HIV-negative status. No women reported intimate partner violence (IPV) due to delivering HIVST kits to male partners, except for once incident of IPV reported by a health care provider.

Study participants said that some women may dislike distributing the HIVST kits due to fear of possible negative reactions by male partners, including quarrelling, physical violence, verbal abuse, or being kicked out of their homes. Additionally, participants said men may not like receiving the HIVST kits due to the belief that the man is the head of the household and that any issues related to sexual matters and HIV testing should be introduced by the man and not the woman. Participants also said that they had concerns with the accuracy of the HIVST kit as it uses saliva and not blood. Health care providers said the main challenge with the distribution of HIVST kits by women is confirming whether the kits are being used and whether they are used by the designated male partners as used kits are not being returned to health facilities and few men visit health facilities for a confirmatory test. Other challenges include lack of materials to demonstrate use of the HIVST kit during counseling and frequent test kit stock-outs. Health care providers also reported that some women delayed ANC visits and changed sites to avoid receiving the HIVST kits.

Lessons Learned

Our study shows that ANC women are willing to accept HIVST kits from providers to share with male partners and that men are willing to receive and use HIVST kits delivered to them by their female partners. Similar findings from other studies conducted in Uganda, Malawi, Kenya, and South Africa demonstrate secondary distribution as an acceptable strategy. However, the role of men’s influence in the decision to use HIVST is an important consideration in the Eswatini context. Our results indicate that providers in such programs need more extensive support, such as instruction in counselling ANC women on how to discuss HIVST with male partners, help in ensuring that the information ANC women give providers about the test kits, including test results, is appropriate and accurate, and supplemental materials, such as videos, that can be used to demonstrate to women how to use the test kits. We also find that the reconceptualization of negative masculine stereotypes (e.g., men should be strong; men do not get sick; men possess all the knowledge) into more positive ideas that emphasize men’s positive role as family caregivers and providers could be reflected in the design of a health communication strategy for the scale-up of women-delivered HIVST kits to male partners.

Conclusion

The secondary distribution of HIVST kits to men via ANC women was acceptable among ANC women, their health care providers, and men. However, programs should address the challenge of men’s refusal to test by strengthening the support provided to health care providers in counselling their ANC women and in providing information about HIVST kits and how to use them. Predominant negative conceptualizations of masculinities and the gender stereotypes they reinforce should be addressed by designing a health communication strategy to accompany the scale-up of women-delivered HIVST kits to male partners. Though intimate partner violence was not prevalent, policymakers should consider including IPV screening and prevention services in HIVST programs to prevent or mitigate potential increases in IPV because of women delivering HIVST kits to male partners.

Supplemental Tools and Resources

• ANC Women HIVST Male partners

Contact Information

Name: Philisiwe Khumalo, Kikand Kindandi
City: Hlathikulu, Dvokalwoko, Mkhuzweni, Matsanjeni, Mbabane, and Piggs Peak
Organization: The Elizabeth Glaser Pediatric AIDS Foundation
Email: info@pedaids.org
Phone number: (202) 296-9165

Best Practice Information

Best Practice Title

Implementation of Cervical Cancer Prevention, Screening, and Management Programming Across Select EGPAF-Supported Countries: Spotlighting Lesotho

Best Practice Type

• Intervention

Best Practice Domain

• Accelerating uptake of proven interventions/policies/diagnostics/medicines

Best Practice Primary Audience

• Implementing Partner

Best Practice Description

Introduction

Lesotho has one of the highest estimated cervical cancer incidence rates in the world. In 2020, the estimated crude incidence per 100,000 women was 49.9. EGPAF in Lesotho has been implementing cervical cancer programming since 2013 — in partnership with the Ministry of Health (MOH) — focused on prevention, screening, diagnosis, treatment, and management of cervical cancer among women. In partnership with the MOH, EGPAF in Lesotho established and continues to support Senkatana as the national training center for cervical cancer prevention, screening, and treatment.

Description

Activities for this initiative include:

1. Capacity building and health system strengthening:
   1. Comprehensive & refresher trainings on screening, diagnosis, referral to health providers (physicians, nurses, counselors) • Physicians trained in treatment of pre-cancer of the cervix - then deployed to high-volume sites • Ongoing mentoring and supportive supervision will ensure quality service delivery • Trained nurses clinically attached to the district hospitals for practice and coaching, based on need • Partner with private practitioners to expand and enhance cervical cancer screening services in private clinics • Use of mHealth/information technology systems to support diagnosis of cervical cancer lesions via medical images and case discussion
2. Quality improvement:
   1. Ongoing mentoring and supportive supervision will ensure quality service delivery • Continued liaising between sexual and reproductive (SRH) teams to ensure suitable stock of supplies are available • Implementation of corrective strategies identified by quality improvement teams from highlighted challenges • Use of appointment systems at high volume facilities of women on ART to ensure clinic visits • Utilization of registers and reporting forms to allow for ongoing data monitoring • Weekly review meetings to discuss trends with district teams • WhatsApp groups with district and MOH staff to continue to advocate for prioritizing cervical cancer screening • An audit to determine where SRH nurses are currently stationed and identify need • Engage with IT to operationalize the use of EVA cameras, holding regular demonstrations for site teams
3. Ensure availability and use of equipment and supplies:
   1. Procure and facilitate availability of relevant equipment - colposcopes, LEEP machines, and cold coagulation units - to facilitate screening for cervical cancer • LEEP centers • Thermocoagulation offered in all selected sites as treatment methods for precancerous lesions of the cervix
4. Demand creation
   1. Media education and training on the importance of cervical cancer elimination, community mobilization, and use of clinical literacy materials in the community for women • Mobilize underserved populations including female sex workers, and factory workers for cervical cancer screening • Use of invitation slips to promote the availability and increase uptake of screening services
5. Integration into HIV services
   1. Integrate cervical cancer screening into ART corners and MNCH clinics and train HCWs to introduce it as part of routine antenatal care (ANC), postnatal care (PNC), and HIV care per national guidelines • Community and facility campaigns for women on 3-6 multi-month dispensation (MMD) of ART, calling eligible women to come for screening at facility and providing transport reimbursement • Leverage project resources to implement HPV testing among women on ART for whom VIA is not suitable and do not have access to Pap smears, using GeneXpert • Documentation of screening in ART cards for accurate monitoring via CACX stamps
6. Outreach for service delivery
   1. Conduct targeted outreaches to support some high and medium-volume sites by having outreach teams • For identified sites with unmet needs employ roving temporary SRH nurses to provide cervical cancer screening and capacitate site level nurses on use of thermocoagulators • Conduct community outreaches including at factory workplaces for demand creation of cervical cancer screening services • Collaborate with community-based partners (
7. Treatment & linkage
   1. Phone calls and SMS to identify and connect with clients to come for treatment • Transportation reimbursement for women in need of treatment to reduce barrier to access and utilization

Data Collection

We collected data on the monthly cervical cancer screening trends from October 2019 to March 2022 in Lesotho; Cervical cancer screening results among WLHIV in Lesotho from October 2018 to March 2022; Cervical cancer cascade among WLHIV 15+ years in Lesotho over 12 months (April 2021-March 2022); and Cervical cancer treatment trends over time among WLHIV who received a positive or suspected result after screening

Results, Outputs, and Outcomes

1. From October 2018 to March 2022, over 98,000 WLHIV were screened for cervical cancer at EGPAF-supported sites. The dips and increases evident in the figure reflect various occurrences that impacted health seeking and utilization. These include holiday festivities (October-December 2019); COVID-19 lockdowns (March-April 2020 and June-July 2020); the absence of SRH nurses at facilities (October 2020); and the re-deployment of temporary SRH nurses (February 2021).

Between October 2018 to March 2022, the average cancer screening positivity across supported sites in Lesotho was 7.6% among WLHIV who were screened and received a result. Figure 5 depicts the results of cervical cancer screening over time. The positivity among WLHIV screened varied from a high of 14.5% (359/2481) in March 2019 to a low of 2.7% (71/2635) in February 2022.

Referral and utilization of appropriate treatment is essential for the timely and successful management of precancerous or cancerous legions among women with positive or suspected cases. The cervical cancer screening and treatment cascade for Lesotho over a 12-month period is shown in Figure 6. Between April 2021 and March 2022, the overall positivity among approximately 35,000 WLHIV screened for cervical cancer was 4%, with 70.5% receiving treatment. The percent of women who received treatment based on a positive or suspected result ranged from 54.3% to 129.23%, with referrals from outside the Maseru district contributing to surpassing the 100% threshold

Between January and March 2022, over 91% of women with a positive result received appropriate treatment. Thermocoagulation, LEEP, and cryotherapy are the available methods for treating precancers. However, since 2020, the main treatment modalities have been thermocoagulation and LEEP services. Figure 7 illustrates in more depth the frequency at which the three types of treatment were employed over time. There is an increasing trend in the use of LEEP: 68.4% of women on treatment received LEEP over the last 12 months compared to 31.6% who received thermocoagulation.

Lessons Learned

1. The persistence of myths and misconceptions surrounding cervical cancer hinders timely access and uptake of services
   1. Health education, community sensitization, and demand creation are critical to address existing misconceptions, building knowledge, and increasing timely screening for early detection
2. There is low demand and knowledge of prevention and diagnostic services
   1. Community-based demand creation through media and mobilization activities are needed to increase awareness and utilization of screening
   2. Leveraging active listing, searching, and identification of eligible women can assist in the completion of referrals to cervical cancer screening
3. The cost of treatment and utilization of services poses significant barriers for those with suspected and confirmed cancer cases
   1. Offer waivers for cost of treatment with support from the MOH
   2. Provide transport reimbursements to facilitate access and uptake of treatment
   3. Use WhatsApp to provide feedback to women treated by health facilities

4. Collaboration with the MOH and district teams is needed to ensure streamlined and synchronous prioritization of scale up of screening and treatment

5. Align MMD of ARVs for women with cervical cancer follow up appointments to avoid unnecessary additional hospital visits

6. Integrate mechanisms for documentation of cervical cancer

Conclusion

Cervical cancer remains a significant health threat, particularly for WLHIV. A multi-disciplinary, systemic, and integrated approach is needed to ensure access to prevention, diagnosis, and management of this disease. The repercussions for not prioritizing this could result in an estimated doubling of the existing half a million cases and 250,000 deaths annually by 2035.

Supplemental Tools and Resources

• Cervical Cancer PSMP
• What to know about Cervical Cancer
• Program Brief
• Molecular Brief

Contact Information

Name: Oluwasanmi Akintade; Aida Yemane Berhan; Allan Mayi; Puseletso Maja; Cosima Lenz
City: Maseru, Berea, Leribe, Mafeteng, Mohale’s Hoek, Thaba Tseka and Qachas Nek
Organization: The Elizabeth Glaser Pediatric AIDS Foundation
Email: info@pedaids.org
Phone number: (202) 296-9165

Best Practice Information

Best Practice Title

Implementation of an adapted Red Carpet Program model in Malawi: Supporting identification and treatment success among adolescents and youth living with HIV

Best Practice Type

• Intervention

Best Practice Domain

• Promoting early initiation of and adherence to HIV treatment 
• Enhancing retention and long-term engagement in HIV care with viral load suppression 
• Addressing disparities in access to/utilization of HIV services
• Finding and testing HIV unawares, especially young men and women
• Linkage to HIV care and support services
• Improving health-related quality of life and quality of care 

Best Practice Primary Audience

• Donor
• Government/Policy Maker
• Health Department or Ministry of Health
• Implementing Partner

Best Practice Description

Introduction

In Malawi, approximately 46% of the population is younger than 15 years and more than 25% are between 15 and 29 years of age. Because of the overall high HIV prevalence in Malawi (10.6%), the risk of HIV acquisition has been reported to be as high as 50% for adolescents between 15–17 years. Adolescents and youth 10–24 years of age living with HIV experience disproportionately worse outcomes along the HIV cascade, from knowledge of status to engagement in care to viral suppression. In recognizing the need for tailored, youth-responsive programming to address the unique challenges of AYLHIV, EGPAF–Malawi, with support from ViiV Healthcare and in coordination with the Malawi Ministry of Health (MOH), adapted the evidence-based Red Carpet Program (RCP) from Kenya, which focuses on improving linkage and retention in care among AYLHIV.4 In 2020, EGPAF–Malawi contextualized and implemented the youth-driven and responsive facility-based initiative in Blantyre, Malawi.

Description

The RCP in Malawi was adapted to address specific needs identified by young people. Four health facilities located in urban, high-burden areas in Blantyre were selected as pilot project sites (Limbe, Bangwe, Ndirande, and South Lunzu). The overarching goal of RCP in Malawi was to increase the HIV identification, linkage, and retention of AYLHIV in care. The package includes fast-tracked services to reduce barriers for AYLHIV to access and utilize HIV services; VIP experience and youth-friendly services at the facility, supportive learning institutions, and empowered youth peer navigators; and a link to the community to support AYLHIV in accessing adolescent- and youth-friendly and responsive services.

Data Collection

We collected data regarding the trends of adolescents and youth reached at RCP sites and testing yield as well as six months retention at RCP pilot facilities.

Results, Outputs, and Outcomes

Between July 2020 and July 2021, 24,062 adolescents and youth 10–24 years old were screened for HIV testing eligibility by YCs across service delivery points. Overall, HIV testing among eligible adolescent and youth patients improved from 60% (n=1208/2008) prior to the intervention (October–December 2019) to 87% (n=2230/2576) in April–June 2021. The HIV positivity yield of those tested post intervention ranged from 5%– 16% among the four pilot sites, with an average of 8% (n=606/8222) of adolescent and youth testing positive for HIV. Ninety-nine percent of those tested positive were linked to care, initiated on ART and enrolled in RCP.

Lessons Learned

The design, adaptation, and implementation of RCP in Malawi has provided some insightful lessons that will inform adolescent and youth implementation and programming moving forwards. These lessons include the following:

1. 1. The contextualization and adaptation of RCP model was critical to inform design of the RCP package in Malawi
   2. The involvement of young people in designing and implementing RCP package positively impacted identification of HIV, retention in care and outcomes among AYLHIV
   3. The coordination and support of the Malawi MOH was critical in the initial sensitization, roll out, and subsequent scale-up of the initiative
   4. The inclusion of YCs as part of the RCP response teams at each facility ensured client flows and timely access to VIP services
   5. Equipping and empowering YCs in their role supported their ability to identify and link eligible young people from different service delivery points for testing, leading to improved testing rates and higher yield.
   6. The development of adolescent- and youth tailored documentation systems that built on existing registers ensured coordinated and structured documentation of RCP services

Conclusion

Despite the COVID-19 pandemic, the yield and linkage of newly identified AYLHIV was consistently higher from July 2020 to June 2021 compared to before RCP was implemented (October–December 2019). The RCP in Malawi had a significant impact on the retention rates of AYLHIV, increasing the percentage of young people who are virally suppressed. In fact, of the AYLHIV who had a viral load test done and who received their results, 93% (39/42) of AYLHIV were virally suppressed. This shows improvement compared to national statistics of 74% of children 0–14 years, 63% of young men 15–24 years, and 50% of young women ages 15–24 years living with HIV who are not virally suppressed.

Supplemental Tools and Resources

• RCP Model
• Red Carpet toolkit
• Adolescent Conference_Poster_RCP Malawi_final
• Interest 2022- RCP Malawi poster

Contact Information

Name: Shalom Dunga; Felix Gent; Rachel Kanyenda; Andrew Chingati; Cosima Lenz
City: Blantyre and Zomba
Organization: Elizabeth Glaser Pediatric AIDS Foundation
Email: info@pedaids.org
Phone number: (202) 296-9165